Provider Demographics
NPI:1093763542
Name:MCCLAIN, GREGORY DEWAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:DEWAYNE
Last Name:MCCLAIN
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:PO BOX 2667
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-2667
Mailing Address - Country:US
Mailing Address - Phone:407-624-3062
Mailing Address - Fax:407-613-2223
Practice Address - Street 1:200 N JOHN YOUNG PKWY
Practice Address - Street 2:SUITE 203
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-6601
Practice Address - Country:US
Practice Address - Phone:407-624-3062
Practice Address - Fax:407-613-2223
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1489-TEP208600000X
CODR.0055743208600000X
WI50140390200000X
FLME101924208600000X
TXN3408208600000X
MO2013025596208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program