Provider Demographics
NPI:1750319505
Name:MCCLURE, ROBERT BRUCE (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRUCE
Last Name:MCCLURE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:R.
Other - Middle Name:BRUCE
Other - Last Name:MCCLURE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:900 I ST FL 2
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5533
Practice Address - Country:US
Practice Address - Phone:219-324-1960
Practice Address - Fax:219-324-1892
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000983207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100366170Medicaid
IN187680BMedicare ID - Type Unspecified
IN100366170Medicaid