Provider Demographics
NPI:1801995543
Name:MCLEAN, CLINTON RUNNELLS (OD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:RUNNELLS
Last Name:MCLEAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4625
Mailing Address - Country:US
Mailing Address - Phone:203-929-4030
Mailing Address - Fax:203-929-9662
Practice Address - Street 1:880 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4625
Practice Address - Country:US
Practice Address - Phone:203-929-4030
Practice Address - Fax:203-929-9662
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT090000904CT01OtherANTHEM BCBS
CT904000-4749OtherCONNECTICARE
CT4271642OtherAETNA
CT0248660001OtherMEDICARE DMERC SUPPLIER
CTP606621OtherOXFORD HEALTH PLAN
CTT22809Medicare UPIN