Provider Demographics
NPI:1194162230
Name:CLARK, MATTHEW RYAN (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1390 S POTOMAC ST STE 124
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4529
Mailing Address - Country:US
Mailing Address - Phone:303-368-8611
Mailing Address - Fax:303-368-9791
Practice Address - Street 1:15830 BALLANTYNE MEDICAL PL STE 225
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-0760
Practice Address - Country:US
Practice Address - Phone:704-919-1105
Practice Address - Fax:704-910-3163
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023-00924207N00000X, 207ND0101X
SCMMD89666MD207N00000X, 207ND0101X
ORMD195653207ND0101X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty