Provider Demographics
NPI:1235127291
Name:CLARK, KEVIN N (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:N
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:425 MEDICAL DR
Mailing Address - Street 2:STE 101
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4945
Mailing Address - Country:US
Mailing Address - Phone:801-298-9409
Mailing Address - Fax:801-292-1271
Practice Address - Street 1:425 MEDICAL DR
Practice Address - Street 2:STE 101
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4945
Practice Address - Country:US
Practice Address - Phone:801-298-9409
Practice Address - Fax:801-292-1271
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT901831861205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B30252Medicare UPIN
UT000000666Medicare ID - Type Unspecified