Provider Demographics
NPI:1265888937
Name:CLARK, WILLIAM (DPM)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:CLARK
Other - Last Name:PODIATRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PC
Mailing Address - Street 1:6920 MIRAMAR RD STE 106
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2641
Mailing Address - Country:US
Mailing Address - Phone:252-801-7686
Mailing Address - Fax:
Practice Address - Street 1:2345 E 8TH ST STE 105
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2866
Practice Address - Country:US
Practice Address - Phone:858-275-6320
Practice Address - Fax:877-671-6835
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE6015213ES0103X, 213ES0103X
PASC006775213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery