Provider Demographics
NPI:1124321559
Name:MCCLELLAND, RICHARD GEORGE (IDC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GEORGE
Last Name:MCCLELLAND
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185
Mailing Address - Country:US
Mailing Address - Phone:757-887-4016
Mailing Address - Fax:757-887-7190
Practice Address - Street 1:290 4TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185
Practice Address - Country:US
Practice Address - Phone:757-887-4016
Practice Address - Fax:757-887-7190
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman