Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | C-7255 | AR |
Y | 2080A0000X | Adolescent Medicine | C-7255 | AR |
NPI | 1235204140 |
---|---|
Provider Name | Elton Cleveland |
First Address | Little Rock, AR 72202-3510 |
Second Address | Little Rock, AR 72202-3510 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/11/2006 |
Last Update Date | 31/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E41783 | (02) |