Provider Demographics
NPI:1770591620
Name:CLARK, STANLEY CORBIN (MD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:CORBIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9690 S 1300 E
Mailing Address - Street 2:100
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3721
Mailing Address - Country:US
Mailing Address - Phone:801-571-5121
Mailing Address - Fax:801-572-5358
Practice Address - Street 1:9690 S 1300 E
Practice Address - Street 2:100
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3721
Practice Address - Country:US
Practice Address - Phone:801-571-5121
Practice Address - Fax:801-572-5358
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172492-1205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D07567Medicare UPIN
000002726Medicare ID - Type Unspecified