Healthcare Provider Details

I. General information

NPI: 1124090766
Provider Name (Legal Business Name): BRUCE MARTIN MCCLENATHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 REILLY ROAD MCXC-MED-ALL WOAMCK ARMY MEDICAL CENTER
FORT BRAGG NC
28310
US

IV. Provider business mailing address

2817 REILLY ROAD MCXC-COD CREDENTIALS WOMACK ARMY MEDICAL CENTER
FORT BRAGG NC
28310
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8620
  • Fax: 910-907-8610
Mailing address:
  • Phone: 910-907-8922
  • Fax: 910-907-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD-11518
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: