Basic Information
| Provider Information | |||||||||
| NPI: | 1003800558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DENVER OCCUPATIONAL & AVIATION MED. CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3464 S WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802314531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037552900 | ||||||||
| FaxNumber: | 3037550404 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 HAVANA ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802393240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033734456 | ||||||||
| FaxNumber: | 3033734501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KLUCK | ||||||||
| AuthorizedOfficialFirstName: | CLARENCE | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3033734456 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 16150 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | C49821 | 05 | CO | MEDICAID | KW63304 | 01 | CO | BLUESHIELD | OTHER |