Healthcare Provider Details

I. General information

NPI: 1093763542
Provider Name (Legal Business Name): GREGORY DEWAYNE MCCLAIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 LAKEVIEW AVE
PUEBLO CO
81004-3508
US

IV. Provider business mailing address

PO BOX 800022
KANSAS CITY MO
64180-0022
US

V. Phone/Fax

Practice location:
  • Phone: 719-557-3777
  • Fax: 719-557-3775
Mailing address:
  • Phone: 800-953-0104
  • Fax: 303-765-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR.0055743
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2013025596
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME101924
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR.0055743
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1489-TEP
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberN3408
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: