Basic Information
Provider Information | |||||||||
NPI: | 1255326633 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1140 E 3900 S | ||||||||
Address2: | SUITE 390 | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841241228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017434700 | ||||||||
FaxNumber: | 8017434705 | ||||||||
Practice Location | |||||||||
Address1: | 1140 E 3900 S | ||||||||
Address2: | SUITE 390 | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841241228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017434700 | ||||||||
FaxNumber: | 8017434705 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2005 | ||||||||
LastUpdateDate: | 05/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 172793-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
ID | Type | State | Issuer | Description | M-9194 | 01 | ID | MEDICAL LICENSE | OTHER | 172793-1205 | 01 | UT | MEDICAL LICENSE | OTHER |