Provider Demographics
NPI:1861092447
Name:CLARK, ISAIAH DANIEL
Entity type:Individual
Prefix:
First Name:ISAIAH
Middle Name:DANIEL
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22376 N MULLIGAN DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-2353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19510 VAN BUREN BLVD # F3-1045
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-9457
Practice Address - Country:US
Practice Address - Phone:951-215-6829
Practice Address - Fax:951-246-0734
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1066261224Y00000X, 224Y00000X, 224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise PhysiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA872340OtherAMERICAN COLLEGE OF SPORTS MEDICINE