Provider Demographics
NPI:1558485037
Name:MCCLINTIC, VIRGIL MARK JR (OD)
Entity Type:Individual
Prefix:DR
First Name:VIRGIL
Middle Name:MARK
Last Name:MCCLINTIC
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2628 TAMIAMI TRL N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-4409
Mailing Address - Country:US
Mailing Address - Phone:239-649-1650
Mailing Address - Fax:239-649-0858
Practice Address - Street 1:2628 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-4409
Practice Address - Country:US
Practice Address - Phone:239-649-1650
Practice Address - Fax:239-649-0858
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL0001765152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT33541Medicare UPIN
FL20521Medicare ID - Type Unspecified