Provider Demographics
NPI:1366529075
Name:MCCLANE, JOHN W III (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:MCCLANE
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SOUTH 14TH STREET
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034
Mailing Address - Country:US
Mailing Address - Phone:904-261-5741
Mailing Address - Fax:904-261-7383
Practice Address - Street 1:6 SOUTH 14TH STREET
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034
Practice Address - Country:US
Practice Address - Phone:904-261-5741
Practice Address - Fax:904-261-7383
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA887152W00000X
FL1488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00261797CMedicaid
GA00243911BMedicaid
GA00254141BMedicaid
GA959951220AMedicaid
GA41ZCCVVMedicare PIN
GA00243911BMedicaid
GA959951220AMedicaid
GA00261797CMedicaid
GA41ZCCVTMedicare PIN