Provider Demographics
NPI:1275752578
Name:CLARKE, CALLISIA (MD)
Entity Type:Individual
Prefix:
First Name:CALLISIA
Middle Name:
Last Name:CLARKE
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:SURGICAL ONCOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5020
Mailing Address - Fax:414-805-5771
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:SURGICAL ONCOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5020
Practice Address - Fax:414-805-5771
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5611208600000X, 2086X0206X
OH57012026208600000X
WI662052086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320489301Medicaid
TX8DT082OtherBCBS
TX287821YKQHMedicare PIN
TX320489301Medicaid