Provider Demographics
NPI:1427046366
Name:MCCLINTOCK, MARTIN BARRY (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:BARRY
Last Name:MCCLINTOCK
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 1:15421 CLAYTON RD
Mailing Address - Street 2:SUITE G-2
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3161
Mailing Address - Country:US
Mailing Address - Phone:636-227-2707
Mailing Address - Fax:636-227-1216
Practice Address - Street 1:15421 CLAYTON RD
Practice Address - Street 2:SUITE G-2
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3161
Practice Address - Country:US
Practice Address - Phone:636-227-2707
Practice Address - Fax:636-227-1216
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1024Medicare ID - Type Unspecified
A09722Medicare UPIN