Provider Demographics
NPI:1396797965
Name:CLARK, DOUGLAS P (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:P
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 1:6140 TUTT BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-3575
Mailing Address - Country:US
Mailing Address - Phone:719-380-6800
Mailing Address - Fax:719-380-6815
Practice Address - Street 1:6140 TUTT BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-3575
Practice Address - Country:US
Practice Address - Phone:719-380-6800
Practice Address - Fax:719-380-6815
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25050207Q00000X
CO025050207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01250505Medicaid
CO01250505Medicaid
COD24563Medicare UPIN