Provider Demographics
NPI:1386668846
Name:CLARK, DARREL CHRISTIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:DARREL
Middle Name:CHRISTIAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:CHRIS
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:241 N. 4TH ST.
Mailing Address - Street 2:BOX 331
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-0331
Mailing Address - Country:US
Mailing Address - Phone:970-409-9734
Mailing Address - Fax:
Practice Address - Street 1:241 N. 4TH ST.
Practice Address - Street 2:# 331
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81502-0331
Practice Address - Country:US
Practice Address - Phone:970-409-9734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCLO2552OtherBCBS
CO01268143Medicaid
CO080038341OtherRAIL ROAD MEDICARE
COCLO2552OtherBCBS
COC2552Medicare PIN