Provider Demographics
NPI:1760465934
Name:MCLENNON, STEPHEN A (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:MCLENNON
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 1:1015 WEBBER ST STE 100
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3527
Mailing Address - Country:US
Mailing Address - Phone:541-296-4804
Mailing Address - Fax:541-296-3741
Practice Address - Street 1:1015 WEBBER ST STE 100
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3527
Practice Address - Country:US
Practice Address - Phone:541-296-4804
Practice Address - Fax:541-296-3741
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR033881Medicaid
OR00WCWBWAMedicare ID - Type Unspecified
ORR0000WFBCSMedicare PIN
ORR159907Medicare PIN
E18345Medicare UPIN
OR033881Medicaid