Healthcare Provider Details

I. General information

NPI: 1770597122
Provider Name (Legal Business Name): PAMELA LECLAIRE MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E CECIL AVE
NORTH EAST MD
21901-4008
US

IV. Provider business mailing address

213 NORTH ST
ELKTON MD
21921-5512
US

V. Phone/Fax

Practice location:
  • Phone: 410-398-4679
  • Fax:
Mailing address:
  • Phone: 410-398-4679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0059903
License Number StateMD

VIII. Authorized Official

Name: JESSICA CORNELL
Title or Position: CREDENTIALING
Credential:
Phone: 410-398-4679