Provider Demographics
NPI:1396859054
Name:CLEVELAND, CRAIG WEBSTER (OD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:WEBSTER
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-2702
Mailing Address - Country:US
Mailing Address - Phone:662-728-6191
Mailing Address - Fax:662-728-9430
Practice Address - Street 1:202 N 2ND ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2702
Practice Address - Country:US
Practice Address - Phone:662-728-6191
Practice Address - Fax:662-728-9430
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880096Medicaid
MS06985007Medicaid
T20824Medicare UPIN