Provider Demographics
NPI:1881612653
Name:CLARK, CLIFFORD D (MD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CLIFFORD
Other - Middle Name:D
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2500 E PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9718
Mailing Address - Country:US
Mailing Address - Phone:970-439-0112
Mailing Address - Fax:
Practice Address - Street 1:2500 E PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9718
Practice Address - Country:US
Practice Address - Phone:970-493-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0047585207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00755984OtherRR MEDICARE
WY12688200Medicaid
CO66729378Medicaid
WY12688200Medicaid