Provider Demographics
NPI:1447251822
Name:CLARK, THOMAS W (DPM)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 RUSSELL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7485
Mailing Address - Country:US
Mailing Address - Phone:717-273-3521
Mailing Address - Fax:717-273-5172
Practice Address - Street 1:918 RUSSELL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7485
Practice Address - Country:US
Practice Address - Phone:717-273-3521
Practice Address - Fax:717-273-5172
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003084L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABC1030193OtherDEA REGISTRATION
PAT30372Medicare UPIN
PA428059Medicare PIN