Provider Demographics
NPI:1427130335
Name:LARSEN, CLARK C (DPM)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:C
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5801 FASHION BLVD
Mailing Address - Street 2:#120
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6159
Mailing Address - Country:US
Mailing Address - Phone:801-261-1391
Mailing Address - Fax:801-261-1394
Practice Address - Street 1:5801 FASHION BLVD
Practice Address - Street 2:#120
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6159
Practice Address - Country:US
Practice Address - Phone:801-261-1391
Practice Address - Fax:801-261-1394
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5750318-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTV11366Medicare UPIN
UT000060036Medicare PIN