Provider Demographics
NPI:1235257973
Name:MCLELLAN, DAVID MONTGOMERY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MONTGOMERY
Last Name:MCLELLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1708 LOCUST AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1332
Mailing Address - Country:US
Mailing Address - Phone:304-363-5799
Mailing Address - Fax:304-366-0346
Practice Address - Street 1:1708 LOCUST AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1332
Practice Address - Country:US
Practice Address - Phone:304-363-5799
Practice Address - Fax:304-366-0346
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV13066204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0128367000Medicaid
WV0128367000Medicaid
WV0795331Medicare ID - Type Unspecified