Basic Information
| Provider Information | |||||||||
| NPI: | 1871518969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LECLAIR | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70368 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974750120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414852777 | ||||||||
| FaxNumber: | 5412462353 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 MARTIN LUTHER KING JR PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974777514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414852777 | ||||||||
| FaxNumber: | 5412462353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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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 | 106H00000X | LF00001937 | OR | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 207VG0400X | MD09743 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 233437 | 05 | OR | MEDICAID |