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: 07/21/2022
Certification Date: 07/21/2022
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 TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 5
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