Provider Demographics
NPI:1639180961
Name:CLANCY, MATTHEW THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:CLANCY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8001 WOODBINE LN
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-8467
Mailing Address - Country:US
Mailing Address - Phone:715-355-6031
Mailing Address - Fax:715-847-2614
Practice Address - Street 1:333 PINE RIDGE BLVD
Practice Address - Street 2:SUITE 317
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4102
Practice Address - Country:US
Practice Address - Phone:715-847-2837
Practice Address - Fax:715-847-2614
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41861-0202083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine