Provider Demographics
NPI:1952336828
Name:MCCLUSKEY, TABB (DO)
Entity Type:Individual
Prefix:DR
First Name:TABB
Middle Name:
Last Name:MCCLUSKEY
Suffix:
Gender:M
Credentials:DO
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 26
Mailing Address - Street 2:501 E LINCOLN ST
Mailing Address - City:HENDRICKS
Mailing Address - State:MN
Mailing Address - Zip Code:56136-0026
Mailing Address - Country:US
Mailing Address - Phone:507-275-3121
Mailing Address - Fax:507-275-3194
Practice Address - Street 1:501 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:HENDRICKS
Practice Address - State:MN
Practice Address - Zip Code:56136-0026
Practice Address - Country:US
Practice Address - Phone:507-275-3121
Practice Address - Fax:507-275-3194
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E80865Medicare UPIN