Healthcare Provider Details

I. General information

NPI: 1194162230
Provider Name (Legal Business Name): MATTHEW RYAN CLARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2353 NE CONNERS AVE
BEND OR
97701-6068
US

IV. Provider business mailing address

2353 NE CONNERS AVE
BEND OR
97701-6068
US

V. Phone/Fax

Practice location:
  • Phone: 541-323-7546
  • Fax:
Mailing address:
  • Phone: 541-323-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMMD89666MD
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMMD89666MD
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2023-00924
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2023-00924
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD195653
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: