Provider Demographics
NPI:1275739070
Name:CLEARY, THOMAS LEO III (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEO
Last Name:CLEARY
Suffix:III
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:618 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-5000
Practice Address - Country:US
Practice Address - Phone:804-443-6297
Practice Address - Fax:804-443-6150
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241758207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA12102701OtherCAQH
VA1275739070Medicaid
VAP00935342Medicare PIN
VAVV1722AMedicare PIN