Basic Information
| Provider Information | |||||||||
| NPI: | 1760872071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | STEPHEN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4403 HARRISON BLVD STE 700A | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033295 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4403 HARRISON BLVD STE 700A | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013875300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2015 | ||||||||
| LastUpdateDate: | 07/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | 20A18092 | CA | N | Other Service Providers | Military Health Care Provider | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.