Provider Demographics
NPI:1902964125
Name:MCCLAVE, GAIL K (MD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:K
Last Name:MCCLAVE
Suffix:
Gender:F
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:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-0393
Mailing Address - Country:US
Mailing Address - Phone:541-347-2111
Mailing Address - Fax:541-347-1212
Practice Address - Street 1:475 ELMIRA AVE SE
Practice Address - Street 2:SUITE103
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-7405
Practice Address - Country:US
Practice Address - Phone:541-347-2111
Practice Address - Fax:541-347-1212
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23131207Q00000X
LA188290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287386Medicaid
ORR13306OtherMEDICARE PTAN
G79392Medicare UPIN