Provider Demographics
NPI:1568690774
Name:MCCLELLAND, EWING R (OD)
Entity Type:Individual
Prefix:DR
First Name:EWING
Middle Name:R
Last Name:MCCLELLAND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8999
Mailing Address - Fax:
Practice Address - Street 1:3500 S COLLEGE AVE STE 180
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2660
Practice Address - Country:US
Practice Address - Phone:970-498-8388
Practice Address - Fax:970-498-8380
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001861152W00000X
COOPT.0003092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33756236Medicaid
VA1568690774Medicaid