Provider Demographics
NPI:1235245481
Name:MCLEOD, METTISA R K (MD)
Entity Type:Individual
Prefix:MRS
First Name:METTISA
Middle Name:R K
Last Name:MCLEOD
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:4500 MEMORIAL DRIVE
Mailing Address - Street 2:MEMORIAL HOSPITAL CREDENTIALING DEPT
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-4061
Mailing Address - Country:US
Mailing Address - Phone:618-257-4644
Mailing Address - Fax:618-257-6946
Practice Address - Street 1:501 BELT LINE RD
Practice Address - Street 2:SUITE 20-D
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4410
Practice Address - Country:US
Practice Address - Phone:618-343-6005
Practice Address - Fax:618-343-9114
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2015-06-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036113800207QA0000X, 207Q00000X, 207QA0505X, 207QG0300X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK20798Medicare ID - Type Unspecified
ILI41099Medicare UPIN