Provider Demographics
NPI:1679574826
Name:MCCLELLAN, DAVID MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:MCCLELLAN
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:PO BOX 1969
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:TX
Mailing Address - Zip Code:77532-7969
Mailing Address - Country:US
Mailing Address - Phone:281-328-4888
Mailing Address - Fax:281-328-8345
Practice Address - Street 1:5214 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:TX
Practice Address - Zip Code:77532-5825
Practice Address - Country:US
Practice Address - Phone:281-328-4888
Practice Address - Fax:281-328-8345
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2009-01-14
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-14
Provider Licenses
StateLicense IDTaxonomies
TXG0476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z953OtherMEDICARE PIN
TX8F9345Medicare PIN
TXB24709Medicare UPIN