Provider Demographics
NPI:1386759041
Name:CLARK, WILLIAM MATT (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MATT
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1954 FORT UNION BLVD
Mailing Address - Street 2:111
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6800
Mailing Address - Country:US
Mailing Address - Phone:801-993-9551
Mailing Address - Fax:801-733-5872
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-588-3272
Practice Address - Fax:801-588-3279
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT170625-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTPRA01666OtherMOLINA
UT107010384101OtherIHC
UTQM0000049510OtherALTIUS
UT17965OtherPEHP
MT401765Medicaid
UT2000040OtherUNITED HEALTHCARE
UT2430OtherHEALTHY U
UT416932OtherDESERET MUTUAL
UT870280408CL2OtherEDUCATORS MUTUAL