Individual
JUSTIN CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
BOCO
Taxonomy
Speciality
Code
Description
License number
State
222Z00000X
Orthotist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GFC000180
—
CA
01
—
PG0073849001
BLUE SHIELD OF CA
CA
Enumeration date
02/28/2018
Last updated
03/17/2018
Update your record
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