Provider Demographics
NPI:1619993755
Name:MCCLATCHEY, RONALD T (OD)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:T
Last Name:MCCLATCHEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1700 SOUTH PARK
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001
Mailing Address - Country:US
Mailing Address - Phone:269-342-0003
Mailing Address - Fax:269-342-4284
Practice Address - Street 1:2350 44TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5016
Practice Address - Country:US
Practice Address - Phone:616-281-1011
Practice Address - Fax:616-281-4941
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002407152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U21018Medicare UPIN