Provider Demographics
NPI:1407812480
Name:CLEVELAND, TREVOR JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:JOHN
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:TREVOR
Other - Middle Name:JOHN
Other - Last Name:CLEVELAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:840 A ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4710
Mailing Address - Country:US
Mailing Address - Phone:541-747-0616
Mailing Address - Fax:541-747-0617
Practice Address - Street 1:840 A ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4710
Practice Address - Country:US
Practice Address - Phone:541-747-0616
Practice Address - Fax:541-747-0617
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2697ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR208294Medicaid
OR3011OtherLIPA
OR3011OtherLIPA
U71633Medicare UPIN