Provider Demographics
NPI:1972615136
Name:CLEARY, DAN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:THOMAS
Last Name:CLEARY
Suffix:
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 1:1185 CORPORATE CENTER DR
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4887
Mailing Address - Country:US
Mailing Address - Phone:262-928-8400
Mailing Address - Fax:262-928-8484
Practice Address - Street 1:1185 CORPORATE CENTER DR
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4887
Practice Address - Country:US
Practice Address - Phone:262-928-8400
Practice Address - Fax:262-928-8484
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21232207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30106700Medicaid
WIB52116Medicare UPIN
WI30106700Medicaid