Provider Demographics
NPI:1518925312
Name:CLEVER, HENRY W III (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:W
Last Name:CLEVER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301
Mailing Address - Country:US
Mailing Address - Phone:636-916-1300
Mailing Address - Fax:636-916-1561
Practice Address - Street 1:901 S 5TH ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301
Practice Address - Country:US
Practice Address - Phone:636-916-1300
Practice Address - Fax:636-916-1561
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4P68207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203348628Medicaid
MO074225734Medicare PIN
MO203348628Medicaid
MO000007422Medicare ID - Type Unspecified