Provider Demographics
NPI:1649532466
Name:CLARK, BRADLEY J (DO)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3500
Mailing Address - Fax:801-475-3494
Practice Address - Street 1:145 S 3000 W
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:UT
Practice Address - Zip Code:84015
Practice Address - Country:US
Practice Address - Phone:801-475-3960
Practice Address - Fax:801-475-3961
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9399538-1204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000092006Medicare PIN