Provider Demographics
NPI:1356326763
Name:THOMAS, CLARENCE HENRY (MD)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:HENRY
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TOM
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6021 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46221
Mailing Address - Country:US
Mailing Address - Phone:317-856-5565
Mailing Address - Fax:317-856-1202
Practice Address - Street 1:6021 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221
Practice Address - Country:US
Practice Address - Phone:317-856-5565
Practice Address - Fax:317-856-1202
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000386020OtherANTHEM
IN100060820Medicaid
IN000000386020OtherANTHEM
INC24317Medicare UPIN