Provider Demographics
NPI:1811911662
Name:MCLEAN, MICHAEL ROY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROY
Last Name:MCLEAN
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:PO BOX 632749
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-2749
Mailing Address - Country:US
Mailing Address - Phone:936-560-2990
Mailing Address - Fax:936-560-5734
Practice Address - Street 1:1300 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4029
Practice Address - Country:US
Practice Address - Phone:936-560-2990
Practice Address - Fax:936-560-5734
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2718207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81K363OtherBLUE CROSS BLUE SHIELD
TX0825200-01Medicaid
TXCP7850Medicare ID - Type UnspecifiedRAILROAD MEDICARE
TX00F82YMedicare ID - Type Unspecified
TX0825200-01Medicaid