Provider Demographics
NPI:1578625612
Name:CLEGG, BARRY ANDREW (OD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:ANDREW
Last Name:CLEGG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:ANDREW
Other - Middle Name:
Other - Last Name:CLEGG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 1555
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-1555
Mailing Address - Country:US
Mailing Address - Phone:541-772-2895
Mailing Address - Fax:541-772-0531
Practice Address - Street 1:2352 POPLAR DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5297
Practice Address - Country:US
Practice Address - Phone:541-772-2895
Practice Address - Fax:541-772-0531
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2531T152W00000X
MT620152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR075965Medicaid
ORV08235Medicare UPIN
OR133839Medicare ID - Type UnspecifiedMEDICARE PART B