Provider Demographics
NPI:1992977342
Name:MCCLURE, TIMOTHY DALE (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DALE
Last Name:MCCLURE
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 1:525 EAST 68TH STREET
Mailing Address - Street 2:STARR 946
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:646-962-9600
Mailing Address - Fax:
Practice Address - Street 1:525 EAST 68TH STREET
Practice Address - Street 2:STARR 946
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:646-962-9600
Practice Address - Fax:646-962-0715
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA959762085R0202X, 208800000X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A959760Medicare Oscar/Certification
CAHG986ZMedicare PIN