Healthcare Provider Details

I. General information

NPI: 1285617928
Provider Name (Legal Business Name): CLARK K. LOFTUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MEDICAL DR #100
BOUNTIFUL UT
84010-5084
US

IV. Provider business mailing address

620 MEDICAL DR #100
BOUNTIFUL UT
84010-5084
US

V. Phone/Fax

Practice location:
  • Phone: 801-295-2888
  • Fax: 801-295-0311
Mailing address:
  • Phone: 801-295-2888
  • Fax: 801-295-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40502
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number248724-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: