Provider Demographics
NPI:1053722124
Name:JOHN H CLANCY DO AND TARA LEIGH CLANCY DO MEDICAL CORPORATION
Entity type:Organization
Organization Name:JOHN H CLANCY DO AND TARA LEIGH CLANCY DO MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:CLANCY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:760-305-1900
Mailing Address - Street 1:2375 S MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-8788
Mailing Address - Country:US
Mailing Address - Phone:760-305-1900
Mailing Address - Fax:760-305-1910
Practice Address - Street 1:2375 S MELROSE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-8788
Practice Address - Country:US
Practice Address - Phone:760-305-1900
Practice Address - Fax:760-305-1910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9614207R00000X
CA9695208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty