Provider Demographics
NPI:1457244394
Name:MCCLAM, DIONDRE JERREMIAH
Entity type:Individual
Prefix:
First Name:DIONDRE
Middle Name:JERREMIAH
Last Name:MCCLAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 WINESAP RD
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-8326
Mailing Address - Country:US
Mailing Address - Phone:910-612-2599
Mailing Address - Fax:
Practice Address - Street 1:3420 WINESAP RD
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-8326
Practice Address - Country:US
Practice Address - Phone:910-612-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000035097080172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver