1184851230 NPI number — DR. CABE RISO CLARK M.D.

Table of content: DR. CABE RISO CLARK M.D. (NPI 1184851230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184851230 NPI number — DR. CABE RISO CLARK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CABE
Provider Middle Name:
RISO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184851230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84130-0180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-471-1683
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5171 S COTTONWOOD ST
Provider Second Line Business Practice Location Address:
STE 740
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-5704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-507-9700
Provider Business Practice Location Address Fax Number:
801-507-9705
Provider Enumeration Date:
06/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  8780963 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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