Provider Demographics
NPI:1255494183
Name:CLARK, THOMAS W (MS, MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS, MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 J CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1819
Mailing Address - Country:US
Mailing Address - Phone:757-591-9572
Mailing Address - Fax:757-591-9606
Practice Address - Street 1:645 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1819
Practice Address - Country:US
Practice Address - Phone:757-591-9572
Practice Address - Fax:757-591-9606
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050712174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA453810OtherANTHEM
VA7312059Medicaid
VA7312059Medicaid