Provider Demographics
NPI:1548403678
Name:CLARK, TERRY K (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:K
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 982255
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-2255
Mailing Address - Country:US
Mailing Address - Phone:435-602-9767
Mailing Address - Fax:413-683-9923
Practice Address - Street 1:4976 E MEADOWS DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5921
Practice Address - Country:US
Practice Address - Phone:435-602-9767
Practice Address - Fax:413-683-9923
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK2480208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery