Provider Demographics
NPI:1497934202
Name:MCCLUNG, BRAXTON (MD)
Entity type:Individual
Prefix:DR
First Name:BRAXTON
Middle Name:
Last Name:MCCLUNG
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 1:2601 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-7745
Mailing Address - Country:US
Mailing Address - Phone:718-616-3000
Mailing Address - Fax:
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0980822085R0202X
IL0361666702085R0202X
NY3317312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0064093Medicaid
PA1027686330001Medicaid
OHP01083159OtherRAILROAD MEDICARE
OH204881619OtherKAISER
OH204881619259OtherCARESOURCE
OH9079891OtherAETNA
OH0064093Medicaid