Provider Demographics
NPI:1144214123
Name:CEARLOCK, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:CEARLOCK
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 1:1951 51ST ST NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-2460
Mailing Address - Country:US
Mailing Address - Phone:319-449-4052
Mailing Address - Fax:319-442-4153
Practice Address - Street 1:1951 51ST ST NE STE 1
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-2460
Practice Address - Country:US
Practice Address - Phone:319-449-4052
Practice Address - Fax:319-449-4153
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22198207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0192542Medicaid
A01650Medicare UPIN
IA0192542Medicaid