Healthcare Provider Details

I. General information

NPI: 1043265663
Provider Name (Legal Business Name): TIMOTHY M CLARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 RIVERBEND RD STE 100
BOULDER CO
80301-2618
US

IV. Provider business mailing address

5450 WESTERN AVE
BOULDER CO
80301-2709
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-5399
  • Fax: 303-297-5808
Mailing address:
  • Phone: 303-415-5399
  • Fax: 303-297-5808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number38716
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number38716
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: