Provider Demographics
NPI:1063503209
Name:CLELAND, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:CLELAND
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:PO BOX 1468
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30603-1468
Mailing Address - Country:US
Mailing Address - Phone:706-549-8682
Mailing Address - Fax:706-549-8682
Practice Address - Street 1:740 PRINCE AVENUE
Practice Address - Street 2:BUILDING 13
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5906
Practice Address - Country:US
Practice Address - Phone:706-549-8682
Practice Address - Fax:706-549-8684
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037175207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00612697IMedicaid
GA00612697IMedicaid
GA11BDHLDMedicare ID - Type Unspecified