Healthcare Provider Details

I. General information

NPI: 1679801229
Provider Name (Legal Business Name): MATTHEW HOUSTON CLARK MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SUPERIOR AVE SUITE 225
NEWPORT BEACH CA
92663-3637
US

IV. Provider business mailing address

520 SUPERIOR AVE SUITE 225
NEWPORT BEACH CA
92663-3637
US

V. Phone/Fax

Practice location:
  • Phone: 949-360-0300
  • Fax:
Mailing address:
  • Phone: 949-360-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW H. CLARK
Title or Position: OWNER
Credential: M.D.
Phone: 949-360-0300