Healthcare Provider Details

I. General information

NPI: 1821034877
Provider Name (Legal Business Name): LARRY K CLARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10465 PARK MEADOWS DR STE 104
LONE TREE CO
80124
US

IV. Provider business mailing address

10465 PARK MEADOWS DR STE 104
LONE TREE CO
80124-5320
US

V. Phone/Fax

Practice location:
  • Phone: 303-799-7903
  • Fax:
Mailing address:
  • Phone: 303-799-7903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDR.0049678
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: