Provider Demographics
NPI:1255326633
Name:CLARK, STEVEN L (MD)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:L
Last Name:CLARK
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 1:1140 E 3900 S
Mailing Address - Street 2:SUITE 390
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1228
Mailing Address - Country:US
Mailing Address - Phone:801-743-4700
Mailing Address - Fax:801-743-4705
Practice Address - Street 1:6651 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2351
Practice Address - Country:US
Practice Address - Phone:832-824-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2648207VM0101X
UT172793-1205207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-9194OtherMEDICAL LICENSE
UT172793-1205OtherMEDICAL LICENSE
IDM-9194OtherMEDICAL LICENSE
UTD20477Medicare UPIN
ID1100033Medicare PIN