Provider Demographics
NPI:1275789307
Name:S. CORBIN CLARK M.D.P.C.
Entity Type:Organization
Organization Name:S. CORBIN CLARK M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:S.
Authorized Official - Middle Name:CORBIN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MDPC
Authorized Official - Phone:801-571-5121
Mailing Address - Street 1:9690 S 1300 E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3721
Mailing Address - Country:US
Mailing Address - Phone:801-571-5121
Mailing Address - Fax:
Practice Address - Street 1:9690 S 1300 E
Practice Address - Street 2:SUITE 100
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3721
Practice Address - Country:US
Practice Address - Phone:801-571-5121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172492-1205261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD07567Medicare UPIN
UT000002726Medicare PIN