Provider Demographics
NPI:1235122052
Name:CLARK, DENISE MAUREEN (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MAUREEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24690 BENCH LN
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:CO
Mailing Address - Zip Code:80467-8545
Mailing Address - Country:US
Mailing Address - Phone:970-879-7241
Mailing Address - Fax:
Practice Address - Street 1:24690 BENCH LN
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:CO
Practice Address - Zip Code:80467-8545
Practice Address - Country:US
Practice Address - Phone:970-879-7241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30559208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2123158Medicaid
IA24232OtherWELLMARK
G03286Medicare UPIN