Provider Demographics
NPI:1407820418
Name:CLARK, BRENT A (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2762 TRASIMENO DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST.GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:509-301-1565
Mailing Address - Fax:509-414-6455
Practice Address - Street 1:2762 TRASIMENO DRIVE
Practice Address - Street 2:
Practice Address - City:ST.GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:509-301-1565
Practice Address - Fax:509-414-6455
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000693213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8275620Medicaid
WA4800319393OtherRAIL ROAD MEDICARE
OR230612Medicaid
WA148232OtherL&I
ID807068300Medicaid
WAU84927Medicare UPIN
WAGAB21630Medicare PIN