Provider Demographics
NPI:1043358096
Name:CASS, CLEANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:CLEANNE
Middle Name:
Last Name:CASS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 WILMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420
Mailing Address - Country:US
Mailing Address - Phone:937-256-4490
Mailing Address - Fax:937-256-5951
Practice Address - Street 1:324 WILMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420
Practice Address - Country:US
Practice Address - Phone:937-256-4490
Practice Address - Fax:937-256-5951
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002318207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0295783Medicaid
OH0295783Medicaid
OH0407792Medicare ID - Type Unspecified