Provider Demographics
NPI:1497717011
Name:MOESINGER, ROBERT CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CLARK
Last Name:MOESINGER
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:801-387-7450
Mailing Address - Fax:801-387-7460
Practice Address - Street 1:4403 HARRISON BLVD STE 1635
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3272
Practice Address - Country:US
Practice Address - Phone:801-387-7450
Practice Address - Fax:801-387-7460
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046382208600000X
UT6214940-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057062Medicaid
MD486700900Medicaid
000059409Medicare PIN
UT000063429Medicare PIN
MDH01641Medicare UPIN