Basic Information
| Provider Information | |||||||||
| NPI: | 1497784110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PADDOCK | ||||||||
| FirstName: | CLARK | ||||||||
| MiddleName: | STUART | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1904 N HELIOTROPE DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927062538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146240772 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23962 ALICIA PKWY | ||||||||
| Address2: | SUITE I1 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926913940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494527699 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 04/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A51251 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A512510 | 05 | CA | MEDICAID |