Provider Demographics
NPI:1003993486
Name:MCLELLAN, JOHN MATHESON (MDCM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MATHESON
Last Name:MCLELLAN
Suffix:
Gender:M
Credentials:MDCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5009
Mailing Address - Country:US
Mailing Address - Phone:802-442-8182
Mailing Address - Fax:
Practice Address - Street 1:140 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-5009
Practice Address - Country:US
Practice Address - Phone:802-442-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0005310207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT03-0354915OtherTAX ID
VT0004563Medicaid
VT0004563Medicaid
VTVT9667Medicare ID - Type Unspecified