Basic Information
| Provider Information | |||||||||
| NPI: | 1386759041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | MATT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1954 FORT UNION BLVD | ||||||||
| Address2: | 111 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841216800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939551 | ||||||||
| FaxNumber: | 8017335872 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841131103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015883272 | ||||||||
| FaxNumber: | 8015883279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 170625-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | PRA01666 | 01 | UT | MOLINA | OTHER | 107010384101 | 01 | UT | IHC | OTHER | QM0000049510 | 01 | UT | ALTIUS | OTHER | 17965 | 01 | UT | PEHP | OTHER | 401765 | 05 | MT | MEDICAID | 2000040 | 01 | UT | UNITED HEALTHCARE | OTHER | 2430 | 01 | UT | HEALTHY U | OTHER | 416932 | 01 | UT | DESERET MUTUAL | OTHER | 870280408CL2 | 01 | UT | EDUCATORS MUTUAL | OTHER |