Provider Demographics
NPI:1558364398
Name:MCLEAN, ROBERT C (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:MCLEAN
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 1:1200 S FARMERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5941
Mailing Address - Country:US
Mailing Address - Phone:318-255-3690
Mailing Address - Fax:318-251-6116
Practice Address - Street 1:1200 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5941
Practice Address - Country:US
Practice Address - Phone:318-255-3690
Practice Address - Fax:318-251-6116
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0041367207Y00000X
TXQ9675207Y00000X
LA333854207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO35883545Medicaid
COC504858OtherMEDICARE PTAN
TX348986603Medicaid
COC504858OtherMEDICARE PTAN
CO35883545Medicaid
COC504868Medicare PIN