Provider Demographics
NPI:1437157260
Name:CLARKE, STACEY J (DPM)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:CLARKE
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 1:82013 DOCTOR CARREON BLVD STE H
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5832
Mailing Address - Country:US
Mailing Address - Phone:760-610-8398
Mailing Address - Fax:442-300-2925
Practice Address - Street 1:82013 DOCTOR CARREON BLVD STE H
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5832
Practice Address - Country:US
Practice Address - Phone:760-610-8398
Practice Address - Fax:442-300-2925
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00283213ES0103X
CAE5243213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150541Medicaid
ORU30842Medicare UPIN
OR4222100001Medicare NSC
OR150541Medicaid