Healthcare Provider Details

I. General information

NPI: 1982617619
Provider Name (Legal Business Name): MCCLANE & STUBITS OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 S 14TH ST
FERNANDINA BEACH FL
32034-3212
US

IV. Provider business mailing address

6 S 14TH ST
FERNANDINA FL
32034-3212
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-5741
  • Fax: 904-261-7383
Mailing address:
  • Phone: 904-261-5741
  • Fax: 904-261-7383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1488
License Number StateFL

VIII. Authorized Official

Name: DR. JOHN W MCCLANE III
Title or Position: PRESIDENT OWNER
Credential: OD
Phone: 904-261-5741