Provider Demographics
NPI:1932294410
Name:MCLAIN, GORDON GLEN (OD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:GLEN
Last Name:MCLAIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 VERBENA PL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361
Mailing Address - Country:US
Mailing Address - Phone:308-220-4646
Mailing Address - Fax:308-220-4548
Practice Address - Street 1:3322 AVE I
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361
Practice Address - Country:US
Practice Address - Phone:308-220-4646
Practice Address - Fax:308-220-4548
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE851152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025-0512.00Medicaid
NE10025-0512.00Medicaid