Provider Demographics
NPI:1669811915
Name:CLARK, SETH (DPM)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 E BELL RD STE 170
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9385
Mailing Address - Country:US
Mailing Address - Phone:623-544-9090
Mailing Address - Fax:623-546-3704
Practice Address - Street 1:4550 E BELL RD STE 170
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9385
Practice Address - Country:US
Practice Address - Phone:623-544-9090
Practice Address - Fax:623-546-3704
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTINTERN213ES0103X
AZ0838213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery