Healthcare Provider Details

I. General information

NPI: 1477580207
Provider Name (Legal Business Name): MICHAEL R. MCCLUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 NE HOYT ST SUITE 651
PORTLAND OR
97213-2991
US

IV. Provider business mailing address

417 SW 117TH AVE SUITE 120
PORTLAND OR
97225-5924
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-6586
  • Fax: 503-215-6428
Mailing address:
  • Phone: 503-641-7173
  • Fax: 503-641-5254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD10002
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: