Provider Demographics
NPI:1043265663
Name:CLARK, TIMOTHY M (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-5399
Mailing Address - Fax:303-297-5808
Practice Address - Street 1:4820 RIVERBEND RD STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2618
Practice Address - Country:US
Practice Address - Phone:303-415-5399
Practice Address - Fax:303-297-5808
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO38716207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4602509Medicaid
CO4602509Medicaid
H16867Medicare UPIN