Provider Demographics
NPI:1255495743
Name:CLARK, THOMAS G (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-2103
Mailing Address - Country:US
Mailing Address - Phone:727-528-2808
Mailing Address - Fax:727-824-8855
Practice Address - Street 1:2909 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-2103
Practice Address - Country:US
Practice Address - Phone:727-528-2808
Practice Address - Fax:727-824-8855
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003633111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88602YMedicare PIN