Provider Demographics
NPI:1154393445
Name:MCCLERNAN, GARY MARC (DPM)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MARC
Last Name:MCCLERNAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14741 WATERWAY DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-3258
Mailing Address - Country:US
Mailing Address - Phone:727-432-1919
Mailing Address - Fax:
Practice Address - Street 1:14741 WATERWAY DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667
Practice Address - Country:US
Practice Address - Phone:727-432-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2389213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDS9118OtherGROUP RR
FLFS503AOtherGROUP MCARE PTAN
FL019585300Medicaid
ALDS9118OtherRR MCARE IND PTAN
FL65368ZOtherINDIVIDUAL MCARE PTAN
FLPO2389OtherSTATE LICENSE
FLFS503AOtherGROUP MCARE PTAN