Provider Demographics
NPI:1386677813
Name:MCCLURE, SIMON (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:MCCLURE
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 1:1160 JOHNSON AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330
Mailing Address - Country:US
Mailing Address - Phone:304-842-9084
Mailing Address - Fax:304-842-9085
Practice Address - Street 1:1160 JOHNSON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-842-9084
Practice Address - Fax:304-842-9085
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV170452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0115260000Medicaid
WV0115260000Medicaid
F41919Medicare UPIN