Provider Demographics
NPI:1265428940
Name:MCCLELLAN, ROBERT LEE (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEE
Last Name:MCCLELLAN
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 1:115 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1108
Mailing Address - Country:US
Mailing Address - Phone:502-348-5125
Mailing Address - Fax:502-348-2485
Practice Address - Street 1:115 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1108
Practice Address - Country:US
Practice Address - Phone:502-348-5125
Practice Address - Fax:502-348-2485
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY704DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77007045Medicaid
9034601Medicare PIN
KYT54586Medicare UPIN
4970700001Medicare NSC