Provider Demographics
NPI:1134136906
Name:RASMUSSEN, CLARK J (MD)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:J
Last Name:RASMUSSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-266-8850
Mailing Address - Fax:
Practice Address - Street 1:5169 COTTONWOOD ST
Practice Address - Street 2:SUITE 410
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6767
Practice Address - Country:US
Practice Address - Phone:801-266-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3355181205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060998Medicare PIN