Healthcare Provider Details

I. General information

NPI: 1407820418
Provider Name (Legal Business Name): BRENT A CLARK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 E RIVERSIDE DR STE 102
ST GEORGE UT
84790-4454
US

IV. Provider business mailing address

2918 W LESINA HEIGHTS DR
ST GEORGE UT
84770-1474
US

V. Phone/Fax

Practice location:
  • Phone: 509-301-1565
  • Fax: 509-414-6455
Mailing address:
  • Phone: 509-301-1565
  • Fax: 509-414-6455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO00000693
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number135349530501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO00000693
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number02101
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: