Healthcare Provider Details

I. General information

NPI: 1245372739
Provider Name (Legal Business Name): MARYBETH F MCCLURE DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 LINCOLN WAY W
MISHAWAKA IN
46544-1626
US

IV. Provider business mailing address

1411 LINCOLN WAY W
MISHAWAKA IN
46544-1626
US

V. Phone/Fax

Practice location:
  • Phone: 574-259-5666
  • Fax:
Mailing address:
  • Phone: 574-259-5666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number02001001A
License Number StateIN

VIII. Authorized Official

Name: DR. MARYBETH F MCCLURE
Title or Position: PRESIDENT
Credential: DO
Phone: 574-259-5666