Provider Demographics
NPI:1700865748
Name:CLARK, SCOTT A (DPM)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
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 540610
Mailing Address - Street 2:
Mailing Address - City:N SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-0610
Mailing Address - Country:US
Mailing Address - Phone:801-451-6060
Mailing Address - Fax:801-296-0218
Practice Address - Street 1:24 S 1100 E STE 210
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:801-505-5277
Practice Address - Fax:801-505-5280
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106339-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000010533Medicare PIN
UTU32083Medicare UPIN
UT000011930Medicare PIN