Provider Demographics
NPI:1568505691
Name:STAHELI, CLARK JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:JOHN
Last Name:STAHELI
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 1:8555 NORTH HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:DAMMERON VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84783
Mailing Address - Country:US
Mailing Address - Phone:801-429-8000
Mailing Address - Fax:801-429-8150
Practice Address - Street 1:8555 NORTH HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:DAMMERON VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84783
Practice Address - Country:US
Practice Address - Phone:435-574-2546
Practice Address - Fax:435-574-2619
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1481051205207Q00000X
UT148105-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT03698Medicaid
UTD07669Medicare UPIN
UT00551010104Medicare ID - Type Unspecified