Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VF0040X | Female Pelvic Medicine and Reconstructive Surgeon | G85764 | CA |
N | 207VG0400X | Gynecologist | G85764 | CA |
NPI | 1952417339 |
---|---|
Provider Name | Matthew H Clark |
First Address | Newport Beach, CA 92663-3637 |
Second Address | Newport Beach, CA 92663-3637 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2006 |
Last Update Date | 16/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H22559 | (02) | CA |