Basic Information
| Provider Information | |||||||||
| NPI: | 1679781140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1490 E FOREMASTER DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847904488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356289393 | ||||||||
| FaxNumber: | 4356289382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | R-7938 | IA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | A113846 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 8203740-1205 | UT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.