Healthcare Provider Details

I. General information

NPI: 1346994811
Provider Name (Legal Business Name): JOSHUA J CLARK MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 G ST
SPRINGFIELD OR
97477-4227
US

IV. Provider business mailing address

1605 G ST
SPRINGFIELD OR
97477-4227
US

V. Phone/Fax

Practice location:
  • Phone: 541-747-6159
  • Fax: 541-741-7249
Mailing address:
  • Phone: 541-747-6159
  • Fax: 541-741-7249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA JOHN CLARK
Title or Position: PHYSICIAN
Credential: MD
Phone: 801-657-9130