Basic Information
| Provider Information | |||||||||
| NPI: | 1083697395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLUNG | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3560 WILDFLOWER DR | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274108802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365445400 | ||||||||
| FaxNumber: | 3365445401 | ||||||||
| Practice Location | |||||||||
| Address1: | 3560 WILDFLOWER DR | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274108802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365445400 | ||||||||
| FaxNumber: | 3365445401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 9901439 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89129P5 | 05 | NC | MEDICAID |