Provider Demographics
NPI:1447367826
Name:CLARK, EDUARDO E (MD)
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:E
Last Name:CLARK
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:PO BOX 62106
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93160-2106
Mailing Address - Country:US
Mailing Address - Phone:805-681-1761
Mailing Address - Fax:805-681-1768
Practice Address - Street 1:4806 CARPINTERIA AVE
Practice Address - Street 2:
Practice Address - City:CARPINTERIA
Practice Address - State:CA
Practice Address - Zip Code:93013-1935
Practice Address - Country:US
Practice Address - Phone:805-681-1761
Practice Address - Fax:805-681-1768
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G487660Medicaid
CAC35716Medicare UPIN
CA00G487660Medicaid