Provider Demographics
NPI:1386731883
Name:MCCLELLAN, BRUCE CLARK (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:CLARK
Last Name:MCCLELLAN
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:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:MORGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-0787
Mailing Address - Country:US
Mailing Address - Phone:801-821-6541
Mailing Address - Fax:
Practice Address - Street 1:1717 W COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5926
Practice Address - Country:US
Practice Address - Phone:907-451-6682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT188674-8905207Q00000X
WI43497-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1386731883Medicaid