Provider Demographics
NPI:1407266653
Name:MCCLURE, WALLACE (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
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 1:450 POWERS BLVD.
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185
Mailing Address - Country:US
Mailing Address - Phone:931-296-2054
Mailing Address - Fax:
Practice Address - Street 1:450 POWERS BLVD.
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185
Practice Address - Country:US
Practice Address - Phone:931-296-2054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD4230208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice