Provider Demographics
NPI:1346511839
Name:GARY M MCCLERNAN DPM PA
Entity Type:Organization
Organization Name:GARY M MCCLERNAN DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:MCCLERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:727-432-1919
Mailing Address - Street 1:14741 WATERWAY DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-3258
Mailing Address - Country:US
Mailing Address - Phone:727-432-1919
Mailing Address - Fax:727-260-4170
Practice Address - Street 1:14741 WATERWAY DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-3258
Practice Address - Country:US
Practice Address - Phone:727-432-1919
Practice Address - Fax:727-260-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-16
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2389213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDS9118OtherRR MCARE GROUP
FL019585300Medicaid
FLPO2389OtherMEDICAL LICENSE
FLFS503AOtherGROUP MCARE PTAN
FL65368OtherBCBS
FL65368ZOtherINDIVIDUAL MCARE PTAN
FL65368OtherBCBS
FLP01076397OtherRR MCARE IND PTAN
FL390228500Medicaid