Basic Information
| Provider Information | |||||||||
| NPI: | 1053339598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLINTIC | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 S PARK | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693420003 | ||||||||
| FaxNumber: | 2693424284 | ||||||||
| Practice Location | |||||||||
| Address1: | 6123 S WESTNEDGE AVE | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490022811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693277079 | ||||||||
| FaxNumber: | 2693277165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 03/25/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901002757 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1053339598 | 05 | MI | MEDICAID |