Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208100000X | Physical Medicine & Rehabilitation Doctor | 036-114565 | IL |
N | 2081P2900X | Pain Medicine | 036-114565 | IL |
N | 2081P2900X | Pain Medicine | 2004032524 | MO |
NPI | 1215941158 |
---|---|
Provider Name | Aidan M Clarke |
First Address | San Diego, CA 92103-1227 |
Second Address | Palm Springs, CA 92262-4800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/07/2006 |
Last Update Date | 22/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G642920 | BLUE SHIELD (01) | |
036114565 | (05) | IL |
E98751 | (02) |