MEDICARE: DWAYNE ERIC MCCLERKLIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	TL25686	SC
2	207L00000X	Anesthesiology Physician	01012425888	VA

General Provider Information

NPI Number	:	1306054069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DWAYNE ERIC MCCLERKLIN MD

Provider Business Mailing Address
First Line	:	3998 FAIR RIDGE DR
Second Line	:	SUITE # 300
City	:	FAIRFAX
State	:	VA
Zip	:	22033-2921
Country	:	US
Telephone Number	:	703-295-9360
Fax Number	:

Provider Business Practice Location Address
First Line	:	7915 LAKE MANASSAS DR.
Second Line	:	SUITE # 302
City	:	GAINESVILLE
State	:	VA
Zip	:	20155-3260
Country	:	US
Telephone Number	:	571-248-0653
Fax Number	:	571-248-0653

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	03/31/2015

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