Provider Demographics
NPI:1558858464
Name:CLARK, MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 MEDICAL DR STE G3
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3077
Mailing Address - Country:US
Mailing Address - Phone:435-374-2097
Mailing Address - Fax:
Practice Address - Street 1:990 MEDICAL DR STE G3
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302
Practice Address - Country:US
Practice Address - Phone:435-374-2097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10841920-9934152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management