Provider Demographics
NPI:1043259211
Name:CLARK, JEFFERY R (MD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 W 38TH AVE
Mailing Address - Street 2:2ND FLOOR, EPN CRED
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6005
Mailing Address - Country:US
Mailing Address - Phone:303-403-3880
Mailing Address - Fax:303-425-8111
Practice Address - Street 1:2005 FRANKLIN ST
Practice Address - Street 2:MIDTOWN 2 #300
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5401
Practice Address - Country:US
Practice Address - Phone:303-318-2250
Practice Address - Fax:303-318-2252
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO20130208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01201300Medicaid
CO01201300Medicaid
F44362Medicare UPIN