Provider Demographics
NPI:1295760726
Name:MCCLELLAN, DEREK A (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:A
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 EXECUTIVE CAMPUS DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9838
Mailing Address - Country:US
Mailing Address - Phone:614-891-9505
Mailing Address - Fax:614-891-6416
Practice Address - Street 1:507 EXECUTIVE CAMPUS DR
Practice Address - Street 2:SUITE 160
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-9838
Practice Address - Country:US
Practice Address - Phone:614-891-9505
Practice Address - Fax:614-891-6416
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.35075108208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2160781Medicaid