Healthcare Provider Details

I. General information

NPI: 1831400894
Provider Name (Legal Business Name): BENJAMIN T CLARK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 S STAPLEY DR STE 101
MESA AZ
85204-6682
US

IV. Provider business mailing address

25500 N NORTERRA DR
PHOENIX AZ
85085-8200
US

V. Phone/Fax

Practice location:
  • Phone: 480-464-6979
  • Fax: 480-464-6910
Mailing address:
  • Phone: 623-277-1130
  • Fax: 866-837-6575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number006841
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: