Basic Information
| Provider Information | |||||||||
| NPI: | 1497712434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CLIFFORD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5920 MCINTYRE ST | ||||||||
| Address2: | |||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804037445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039491250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5920 MCINTYRE ST | ||||||||
| Address2: | |||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804037445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039491250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 12/01/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0048886 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | DR.0048886 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 850365127 | 01 | NM | FEDERAL TAX ID | OTHER | 91080200 | 05 | CO | MEDICAID | 13094 | 05 | NM | MEDICAID | COA104546 | 01 | CO | MEDICARE NUMBER | OTHER | 8020 | 01 | NM | STATE MEDICAL LICENSE | OTHER |