MEDICARE: CHARLES M MCCLEAN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician	J0590	TX

General Provider Information

NPI Number	:	1144272071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES M MCCLEAN D.O.

Provider Business Mailing Address
First Line	:	3600 MATLOCK RD
Second Line	:	SUITE 106
City	:	ARLINGTON
State	:	TX
Zip	:	76015-3679
Country	:	US
Telephone Number	:	817-557-1900
Fax Number	:	817-557-1942

Provider Business Practice Location Address
First Line	:	3600 MATLOCK RD
Second Line	:	SUITE 106
City	:	ARLINGTON
State	:	TX
Zip	:	76015-3679
Country	:	US
Telephone Number	:	817-557-1900
Fax Number	:	817-557-1942

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	04/15/2011

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