Provider Demographics
NPI:1609175579
Name:MCCLANAHAN, MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MCCLANAHAN
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 1:250 EVANGELINE DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-1882
Mailing Address - Country:US
Mailing Address - Phone:806-535-3781
Mailing Address - Fax:
Practice Address - Street 1:1202 S TYLER ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2330
Practice Address - Country:US
Practice Address - Phone:985-898-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.207948207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program