Provider Demographics
NPI:1225444516
Name:MCCLEAVE, TAHARKA KINGO (DO)
Entity Type:Individual
Prefix:DR
First Name:TAHARKA
Middle Name:KINGO
Last Name:MCCLEAVE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 CLARKSON AVE
Mailing Address - Street 2:BOX 1228
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2012
Mailing Address - Country:US
Mailing Address - Phone:718-245-3318
Mailing Address - Fax:
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:BOX 1228
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2012
Practice Address - Country:US
Practice Address - Phone:718-245-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304303207P00000X
NH21037207P00000X
NJ25MB10861600207P00000X
MI5101025677207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine