Provider Demographics
NPI:1104932888
Name:CLEMENSEN, SCOTT E (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:E
Last Name:CLEMENSEN
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 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:580 MOHAWK DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-3712
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228550207Q00000X
CO47105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP010228650OtherBLUE CHOICE
CO45278857Medicaid
CO19471OtherKAISER COMMERCIAL NUMBER
NY7132714OtherAETNA
NYMDJ022OtherPREFERRED CARE
NYI26466Medicare UPIN
NYRA6052Medicare PIN
CO45278857Medicaid