Healthcare Provider Details

I. General information

NPI: 1568505691
Provider Name (Legal Business Name): CLARK JOHN STAHELI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8555 NORTH HIGHWAY 18
DAMMERON VALLEY UT
84783
US

IV. Provider business mailing address

8555 NORTH HIGHWAY 18
DAMMERON VALLEY UT
84783
US

V. Phone/Fax

Practice location:
  • Phone: 435-574-2546
  • Fax: 435-574-2619
Mailing address:
  • Phone: 801-429-8000
  • Fax: 801-429-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1481051205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number148105-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: