Provider Demographics
NPI:1508124579
Name:ROGER L. MCCLELLAN, MD, INC.
Entity Type:Organization
Organization Name:ROGER L. MCCLELLAN, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-960-7977
Mailing Address - Street 1:6311 TURNBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5584
Mailing Address - Country:US
Mailing Address - Phone:714-960-7977
Mailing Address - Fax:714-960-8534
Practice Address - Street 1:6311 TURNBERRY CIR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-5584
Practice Address - Country:US
Practice Address - Phone:714-960-7977
Practice Address - Fax:714-960-8534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA256902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA25690Medicaid
CAAM13662158OtherDEA
CAA25690Medicaid