Provider Demographics
NPI:1245397850
Name:CLEVELAND, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 UNIVERSITY DR
Mailing Address - Street 2:ENTRANCE 12
Mailing Address - City:DUNBAR
Mailing Address - State:PA
Mailing Address - Zip Code:15431-2050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1829 UNIVERSITY DR
Practice Address - Street 2:ENTRANCE 12
Practice Address - City:DUNBAR
Practice Address - State:PA
Practice Address - Zip Code:15431-2050
Practice Address - Country:US
Practice Address - Phone:724-628-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA0201820363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA099199Medicare ID - Type Unspecified
Q66408Medicare UPIN