Provider Demographics
NPI:1619045093
Name:JOAN MCCLARY
Entity type:Organization
Organization Name:JOAN MCCLARY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCCLARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-757-3774
Mailing Address - Street 1:1612 AUSTIN AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76701-1714
Mailing Address - Country:US
Mailing Address - Phone:254-757-3774
Mailing Address - Fax:254-757-0141
Practice Address - Street 1:1612 AUSTIN AVE
Practice Address - Street 2:STE. C
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1714
Practice Address - Country:US
Practice Address - Phone:254-757-3774
Practice Address - Fax:254-757-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137976010Medicaid
TX137976004Medicaid
TX613833Medicare PIN
TXE51592Medicare UPIN