Provider Demographics
NPI:1902962939
Name:CLARK, GARY BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:BRUCE
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12541 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-5869
Mailing Address - Country:US
Mailing Address - Phone:720-887-5726
Mailing Address - Fax:
Practice Address - Street 1:1790 30TH ST
Practice Address - Street 2:SUITE 230
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1022
Practice Address - Country:US
Practice Address - Phone:303-444-5131
Practice Address - Fax:303-444-5131
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20926208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice