Provider Demographics
NPI:1609861152
Name:CLARK, GARY W (DPM)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
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:PO BOX 1986
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-1986
Mailing Address - Country:US
Mailing Address - Phone:435-867-8521
Mailing Address - Fax:435-586-4073
Practice Address - Street 1:166 W 1325 N
Practice Address - Street 2:SUITE 300
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-7792
Practice Address - Country:US
Practice Address - Phone:435-867-8521
Practice Address - Fax:435-586-4073
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT320729-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5790180001Medicare NSC
UT000011754Medicare PIN
UTP00399656Medicare PIN
UTU50616Medicare UPIN
UT000060792Medicare PIN