Provider Demographics
NPI:1699762708
Name:CLARK, THOMAS H (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:CLARK
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 1:1300 PICCARD DR
Mailing Address - Street 2:SUITE 202 EMERGENCY MEDICINE ASSOCIATES
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4303
Mailing Address - Country:US
Mailing Address - Phone:301-921-7900
Mailing Address - Fax:301-921-7915
Practice Address - Street 1:4320 SEMINARY ROAD
Practice Address - Street 2:ALEXANDRIA HOSPITAL
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-504-3066
Practice Address - Fax:703-504-3866
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00608745Medicaid
0111OtherCARE FIRST
C88563Medicare UPIN
MD198754E14Medicare ID - Type Unspecified
VA00608745Medicaid