Provider Demographics
NPI:1144404401
Name:BOZEMAN PODIATRIC CLINIC INC
Entity Type:Organization
Organization Name:BOZEMAN PODIATRIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:406-586-5318
Mailing Address - Street 1:300 N WILLSON AVE STE 801H
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3551
Mailing Address - Country:US
Mailing Address - Phone:406-586-5318
Mailing Address - Fax:406-586-1635
Practice Address - Street 1:300 N WILLSON AVE STE 801H
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3551
Practice Address - Country:US
Practice Address - Phone:406-586-5318
Practice Address - Fax:406-586-1635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT79213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009239OtherPTAN
MT0436830001Medicare NSC