Provider Demographics
NPI:1750380267
Name:MCCLUNG, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCCLUNG
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 1:11501 GRANADA LN
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1454
Mailing Address - Country:US
Mailing Address - Phone:913-451-3722
Mailing Address - Fax:913-451-5000
Practice Address - Street 1:11501 GRANADA ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1454
Practice Address - Country:US
Practice Address - Phone:913-451-3722
Practice Address - Fax:913-451-5000
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-220482086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B24714Medicare UPIN
4473291Medicare ID - Type Unspecified