Provider Demographics
NPI:1578526554
Name:MCCLELLAN, JOHN W JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:MCCLELLAN
Suffix:JR
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 1:1015 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2712
Mailing Address - Country:US
Mailing Address - Phone:270-826-8009
Mailing Address - Fax:270-826-7010
Practice Address - Street 1:1015 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2712
Practice Address - Country:US
Practice Address - Phone:270-826-8009
Practice Address - Fax:270-826-7010
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY080113192OtherRR MEDICARE
KY64130123Medicaid
KY000000609932OtherANTHEM BLUE SHIELD
KY000000041669OtherANTHEM
KY000000609932OtherANTHEM BLUE SHIELD
KY0396004Medicare PIN
C64724Medicare UPIN
KYK183110Medicare PIN