Provider Demographics
NPI:1790782084
Name:MCCLELLAND, MICHAEL LYNN JR (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LYNN
Last Name:MCCLELLAND
Suffix:JR
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 1:8240 N MOPAC EXPY STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8869
Mailing Address - Country:US
Mailing Address - Phone:512-477-5905
Mailing Address - Fax:
Practice Address - Street 1:1301 W 38TH ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1010
Practice Address - Country:US
Practice Address - Phone:512-477-5905
Practice Address - Fax:512-477-8640
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4563208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156568102Medicaid
TXH64073Medicare UPIN
TX8F6343Medicare PIN