Provider Demographics
NPI:1093709412
Name:CLARK, DUMONT F (MD)
Entity Type:Individual
Prefix:
First Name:DUMONT
Middle Name:F
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 1:452 S HAHNS PEAK AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-6031
Mailing Address - Country:US
Mailing Address - Phone:719-547-7662
Mailing Address - Fax:719-566-0916
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:SUITE 254
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-564-1542
Practice Address - Fax:719-566-0916
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19963207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01199637Medicaid
D23691Medicare UPIN
B8818Medicare ID - Type Unspecified