Basic Information
| Provider Information | |||||||||
| NPI: | 1326672619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLARY | ||||||||
| FirstName: | CALEB | ||||||||
| MiddleName: | EVAN | ||||||||
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| Credential: | MD (MAY 15, 2020) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13 STAL MAR CIR | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146244614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855370908 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4881 SUGAR MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454335529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372570837 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2020 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | Y | Other Service Providers | Military Health Care Provider |
No ID Information.