Provider Demographics
NPI:1982617619
Name:MCCLANE & STUBITS OD PA
Entity Type:Organization
Organization Name:MCCLANE & STUBITS OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCCLANE
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:904-261-5741
Mailing Address - Street 1:6 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3212
Mailing Address - Country:US
Mailing Address - Phone:904-261-5741
Mailing Address - Fax:904-261-7383
Practice Address - Street 1:6 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3212
Practice Address - Country:US
Practice Address - Phone:904-261-5741
Practice Address - Fax:904-261-7383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078182700Medicaid
FL078226200Medicaid
FL078226200Medicaid
FL19737ZMedicare PIN
FLT84142Medicare UPIN
FL078182700Medicaid
FL0270120002Medicare NSC
FL19041ZMedicare PIN
FLT84153Medicare UPIN
FL19268ZMedicare PIN