MEDICARE: DR. MATTHEW ALEXANDER CLARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	39323	CO
2	208000000X	Pediatrics Physician	39323	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215993308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW ALEXANDER CLARK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 49
Second Line	:
City	:	TOWAOC
State	:	CO
Zip	:	81334-0049
Country	:	US
Telephone Number	:	970-565-4441
Fax Number	:

Provider Business Practice Location Address
First Line	:	UTE MOUNTAIN UTE HEALTH CENTER
Second Line	:	COMPLEX B RUSTLING WILLOW STREET
City	:	TOWAOC
State	:	CO
Zip	:	81334-0049
Country	:	US
Telephone Number	:	970-565-4441
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	10/05/2009

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