Provider Demographics
NPI:1194796037
Name:CLARK, THOMAS A (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29100 GATEWAY BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-2764
Mailing Address - Country:US
Mailing Address - Phone:734-379-9200
Mailing Address - Fax:734-379-9229
Practice Address - Street 1:29100 GATEWAY BLVD
Practice Address - Street 2:STE 100
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-2764
Practice Address - Country:US
Practice Address - Phone:734-379-9200
Practice Address - Fax:734-379-9229
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITC005814111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION57460Medicare ID - Type Unspecified