Provider Demographics
NPI:1851411755
Name:CLARK, JEFFREY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:PAUL
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:652 N 1180 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-5467
Mailing Address - Country:US
Mailing Address - Phone:801-225-2474
Mailing Address - Fax:
Practice Address - Street 1:652 N 1180 E
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5467
Practice Address - Country:US
Practice Address - Phone:801-225-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT178661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC1453721OtherDEA NUMBER VOLUNTARILY RETIRED