Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 036113800 | IL |
N | 207QA0505X | Family Doctor - Adult Medicine | 036113800 | IL |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 036113800 | IL |
N | 207QS0010X | Family Doctor - Sports Medicine | 036113800 | IL |
NPI | 1235245481 |
---|---|
Provider Name | Mrs. Mettisa R. K. Mcleod |
First Address | Belleville, IL 62226-4061 |
Second Address | Collinsville, IL 62234-4410 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2006 |
Last Update Date | 05/06/2015 |