Provider Demographics
NPI:1467432484
Name:HARCLERODE, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:HARCLERODE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LANGLEY PL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-7998
Mailing Address - Country:US
Mailing Address - Phone:719-526-8368
Mailing Address - Fax:719-524-5571
Practice Address - Street 1:1853 OCONNELL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80913-4055
Practice Address - Country:US
Practice Address - Phone:719-526-8368
Practice Address - Fax:719-524-5571
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39999207Q00000X
AZ19638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11488239Medicaid
COC99611Medicare UPIN
CO11488239Medicaid