1104015155 NPI number — DR. THERESA L CLARK M.D.

Table of content: DR. THERESA L CLARK M.D. (NPI 1104015155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104015155 NPI number — DR. THERESA L CLARK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
THERESA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LARKIN
Provider Other First Name:
THERESA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104015155
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2098
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DILLON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80435-2098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-455-9004
Provider Business Mailing Address Fax Number:
949-577-4247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 VILLAGE PLACE
Provider Second Line Business Practice Location Address:
ST 207
Provider Business Practice Location Address City Name:
DILLON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-455-9004
Provider Business Practice Location Address Fax Number:
949-577-4247
Provider Enumeration Date:
10/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  35.135479 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: ME104695 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: TRN11797 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: DR.0061413 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 011243700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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