Healthcare Provider Details

I. General information

NPI: 1700814639
Provider Name (Legal Business Name): STACEY DALE MCCLURE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 W AGUA FRIA FWY STE 103
PHOENIX AZ
85027-7202
US

IV. Provider business mailing address

2730 W AGUA FRIA FWY STE 103
PHOENIX AZ
85027-7202
US

V. Phone/Fax

Practice location:
  • Phone: 480-699-2472
  • Fax:
Mailing address:
  • Phone: 480-699-2472
  • Fax: 480-699-4372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number34081
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number34081
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: