Provider Demographics
NPI:1629140173
Name:GARY W. CLARK INC
Entity Type:Organization
Organization Name:GARY W. CLARK INC
Other - Org Name:GARY W CLARK DPM A PROFESSIONAL CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:435-867-8521
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:
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:84720-7792
Practice Address - Country:US
Practice Address - Phone:435-867-8521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT320729-0501213E00000X
UT3207290501332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529212733004Medicaid
UTU50616Medicare UPIN
UTDF8855Medicare PIN
UT529212733004Medicaid