Provider Demographics
NPI:1033146634
Name:CLARK, JUSTIN S (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1746 COLE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3267
Mailing Address - Country:US
Mailing Address - Phone:303-914-8800
Mailing Address - Fax:
Practice Address - Street 1:1746 COLE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3267
Practice Address - Country:US
Practice Address - Phone:303-914-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1393052085R0202X
MO20200220782085R0202X
WI51149-202085R0202X, 208D00000X
CODR.00697962085R0202X
MT577772085R0202X
SC831762085R0202X
DE645262085R0202X
MA2816342085R0202X
CAC1666872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice