Provider Demographics
NPI:1720128283
Name:CLARK, PHYLLIS VERONICA (MD)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:VERONICA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 E FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6457
Mailing Address - Country:US
Mailing Address - Phone:719-632-8845
Mailing Address - Fax:
Practice Address - Street 1:1375 E FILLMORE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6457
Practice Address - Country:US
Practice Address - Phone:719-632-8845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO27522207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine