Basic Information
| Provider Information | |||||||||
| NPI: | 1134170400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLOUGH | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 PR CTR PKWY | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806014006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034229438 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15502 HILLTOP DR | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806014106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034229438 | ||||||||
| FaxNumber: | 3034229474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2943 | AK | Y | Other Service Providers | Specialist | 207L00000X | DR.0032419 | CO | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CI9459 | 01 | AK | GROUPS RAILROAD MCR# | OTHER | 020257499 | 01 | AK | GROUPS ENERGY EMP# | OTHER | MD1730 | 05 | AK | MEDICAID | 01324193 | 05 | CO | MEDICAID | 193975000 | 01 | AK | GROUPS FED DOL# | OTHER | 050082635 | 01 | AK | CLOUGHS RAILROAD MCR# | OTHER | MDG417 | 05 | AK | MEDICAID |