Healthcare Provider Details

I. General information

NPI: 1679781140
Provider Name (Legal Business Name): RANDY R CLARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 E MALL DR
ST GEORGE UT
84790-1954
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-9393
  • Fax: 435-628-9382
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number8203740-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number8203740-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: