Provider Demographics
NPI:1497161590
Name:CLARK, DEREK (BOCO CPED)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:BOCO CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 JUAN TABO BLVD NE
Mailing Address - Street 2:STE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-200-9004
Mailing Address - Fax:505-271-0217
Practice Address - Street 1:5111 JUAN TABO BLVD NE
Practice Address - Street 2:STE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111
Practice Address - Country:US
Practice Address - Phone:505-200-9004
Practice Address - Fax:505-271-0217
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC49914222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist