Provider Demographics
NPI:1972624146
Name:ASHBY, CLARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:S
Last Name:ASHBY
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:PO BOX 1727
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84603-1727
Mailing Address - Country:US
Mailing Address - Phone:801-375-8049
Mailing Address - Fax:801-374-9195
Practice Address - Street 1:320 RIVER PARK DR STE 125
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5787
Practice Address - Country:US
Practice Address - Phone:801-375-8049
Practice Address - Fax:801-374-9195
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3419161205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG62844Medicare UPIN
UT005793302Medicare ID - Type Unspecified