Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VM0101X | Gynecologist - Maternal & Fetal Medicine | 172793-1205 | UT |
NPI | 1255326633 |
---|---|
Provider Name | Mr. Steven L Clark |
First Address | Salt Lake City, UT 84124-1228 |
Second Address | Salt Lake City, UT 84124-1228 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2005 |
Last Update Date | 07/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
172793-1205 | MEDICAL LICENSE (01) | UT |
D20477 | (02) | UT |
M-9194 | MEDICAL LICENSE (01) | ID |