Provider Demographics
NPI:1821034877
Name:CLARK, LARRY K (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:K
Last Name:CLARK
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 1:10465 PARK MEADOWS DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5320
Mailing Address - Country:US
Mailing Address - Phone:303-799-7903
Mailing Address - Fax:
Practice Address - Street 1:10465 PARK MEADOWS DR STE 104
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124
Practice Address - Country:US
Practice Address - Phone:303-799-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0049678207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202326104Medicaid
160052701OtherRR MEDICARE
MO202326104Medicaid
MO28070OtherANTHEM
160052701OtherRR MEDICARE
OK100089240AMedicaid
A11586Medicare UPIN