Provider Demographics
NPI:1376639047
Name:CLARK, HOLLY (MD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 S 3000 E
Mailing Address - Street 2:#220
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6923
Mailing Address - Country:US
Mailing Address - Phone:801-263-3041
Mailing Address - Fax:801-263-8485
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:SUITE 360
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-263-3041
Practice Address - Fax:801-263-8485
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4977163207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT49771631200001OtherBLUE CROSS BLUE SHIELD
UT49771631200001OtherHEALTHWISE
UT49771631200001OtherVALUE CARE
UT78498OtherPUBLIC EMPLOYEES
UTQM0000217387OtherALTIUS
UT78498OtherPUBLIC EMPLOYEES
UT49771631200001OtherVALUE CARE
UT005505504Medicare ID - Type Unspecified