Healthcare Provider Details

I. General information

NPI: 1790993475
Provider Name (Legal Business Name): JEFFREY CARLYLE MCCLEAN II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR SAMMC NEUROLOGY
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

3551 ROGER BROOKE DR SAMMC NEUROLOGY
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-373-2047
  • Fax: 210-916-3833
Mailing address:
  • Phone: 210-373-2047
  • Fax: 210-916-3833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number24219
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number24219
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: