Provider Demographics
NPI:1952417339
Name:CLARK, MATTHEW H (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:H
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 SUPERIOR AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3637
Mailing Address - Country:US
Mailing Address - Phone:949-360-0300
Mailing Address - Fax:949-360-6932
Practice Address - Street 1:520 SUPERIOR AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3637
Practice Address - Country:US
Practice Address - Phone:949-360-0300
Practice Address - Fax:949-360-6932
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85764207VG0400X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH22559Medicare UPIN
CAG85765Medicare ID - Type Unspecified