Provider Demographics
NPI:1144632183
Name:CLARK, THOMAS JAMES EARL (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES EARL
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 1:925 N 87TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4812
Mailing Address - Country:US
Mailing Address - Phone:414-456-2020
Mailing Address - Fax:414-456-6300
Practice Address - Street 1:925 N 87TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-456-2020
Practice Address - Fax:414-456-6300
Is Sole Proprietor?:No
Enumeration Date:2014-05-26
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE32120207WX0200X
WI68627207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1144632183Medicaid