MEDICARE: DENISE MAUREEN CLARK MD

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	208000000X	Pediatrics Physician	30559	IA

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
2	24232	OTHER	IA	WELLMARK

General Provider Information

NPI Number	:	1235122052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE MAUREEN CLARK MD

Provider Business Mailing Address
First Line	:	24690 BENCH LN
Second Line	:
City	:	OAK CREEK
State	:	CO
Zip	:	80467-8545
Country	:	US
Telephone Number	:	970-879-7241
Fax Number	:

Provider Business Practice Location Address
First Line	:	24690 BENCH LN
Second Line	:
City	:	OAK CREEK
State	:	CO
Zip	:	80467-8545
Country	:	US
Telephone Number	:	970-879-7241
Fax Number	:

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

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	09/16/2009

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