Healthcare Provider Details

I. General information

NPI: 1487887766
Provider Name (Legal Business Name): JUSTIN WILSON MCCLAIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE STE D-112
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

1364 CLIFTON RD NE STE D-112
ATLANTA GA
30322-1059
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-5287
  • Fax: 404-712-7839
Mailing address:
  • Phone: 404-712-5287
  • Fax: 404-712-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME152117
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number079285
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number270632
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: