Provider Demographics
NPI:1669529582
Name:THOMAS J CLARK DO INC
Entity type:Organization
Organization Name:THOMAS J CLARK DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-547-2275
Mailing Address - Street 1:620 CALIFORNIA BLVD.
Mailing Address - Street 2:SUITE J
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2598
Mailing Address - Country:US
Mailing Address - Phone:805-547-2275
Mailing Address - Fax:805-547-2279
Practice Address - Street 1:620 CALIFORNIA BLVD.
Practice Address - Street 2:SUITE J
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2598
Practice Address - Country:US
Practice Address - Phone:805-547-2275
Practice Address - Fax:805-547-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8621261QM2500X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F79595Medicare UPIN
CAZZZ05848ZMedicare PIN