Basic Information
| Provider Information | |||||||||
| NPI: | 1275752578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | CALLISIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | SURGICAL ONCOLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148055020 | ||||||||
| FaxNumber: | 4148055771 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | SURGICAL ONCOLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148055020 | ||||||||
| FaxNumber: | 4148055771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | P5611 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 57012026 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | P5611 | TX | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086X0206X | 66205 | WI | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 320489301 | 05 | TX | MEDICAID | 8DT082 | 01 | TX | BCBS | OTHER |