Provider Demographics
NPI:1164458964
Name:MCCLURE, MARK DOUGLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:MCCLURE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 N BREIEL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3802
Mailing Address - Country:US
Mailing Address - Phone:513-423-7855
Mailing Address - Fax:513-422-4103
Practice Address - Street 1:182 N BREIEL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3802
Practice Address - Country:US
Practice Address - Phone:513-423-7855
Practice Address - Fax:513-422-4103
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1192111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0950958Medicaid
T48431Medicare UPIN
OH0950958Medicaid
OH0586452Medicare PIN
OHT-48431Medicare UPIN