Provider Demographics
NPI:1063627230
Name:MCCLEARY, MICHAEL DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:MCCLEARY
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 1:25 W CRYSTAL LAKE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4475
Mailing Address - Country:US
Mailing Address - Phone:407-254-2522
Mailing Address - Fax:407-254-2557
Practice Address - Street 1:25 W CRYSTAL LAKE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4475
Practice Address - Country:US
Practice Address - Phone:407-254-2522
Practice Address - Fax:407-254-2557
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98424174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35.085825OtherSTATE MEDICAL LICENSE
FLME98424OtherSTATE MEDICAL LICENSE