Provider Demographics
NPI:1811168339
Name:CLARK, JANICE PATRECE (DPM)
Entity type:Individual
Prefix:DR
First Name:JANICE
Middle Name:PATRECE
Last Name:CLARK
Suffix:
Gender:F
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:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:ZUNI
Mailing Address - State:NM
Mailing Address - Zip Code:87327-0467
Mailing Address - Country:US
Mailing Address - Phone:210-842-6826
Mailing Address - Fax:505-782-7330
Practice Address - Street 1:1660 S COLUMBIAN WAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-1532
Practice Address - Country:US
Practice Address - Phone:206-716-5651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001114207XX0004X, 213ES0103X
NMCL011213ES0103X
AZ0689213ES0103X
NYR57676213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA519981OtherWELLCARE
GA52246038-001OtherBCBSGA
GAPAROtherAETNA
GAPAR-2009-07-20OtherGREAT WEST
SCGPD114Medicaid
GA2009-07-20OtherCIGNA
GA294861171AMedicaid
GA1289105OtherAMERIGROUP
GA2009-10-01OtherPSHP
GA20091544OtherSELECT HEALTH
GAPAR-2009-08-28OtherTRICARE
GA2009-08-01OtherUNITED HEALTHCARE
GA20091544OtherSELECT HEALTH