Provider Demographics
NPI:1881781334
Name:ALLEN, EDWARD CLARK (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:CLARK
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 CARMEL VALLEY RD
Mailing Address - Street 2:B
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3772
Mailing Address - Country:US
Mailing Address - Phone:858-877-9804
Mailing Address - Fax:
Practice Address - Street 1:2190 CARMEL VALLEY RD
Practice Address - Street 2:B
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-3772
Practice Address - Country:US
Practice Address - Phone:858-877-9804
Practice Address - Fax:858-724-1820
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA480402084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A480400Medicaid
CA00A480400Medicaid
F29599Medicare UPIN