Provider Demographics
NPI:1528039708
Name:CLELAND, KATHLEEN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:CLELAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13135 LEE JACKSON MEMORIAL HWY STE 305
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1909
Mailing Address - Country:US
Mailing Address - Phone:703-359-8640
Mailing Address - Fax:703-591-6105
Practice Address - Street 1:13135 LEE JACKSON MEMORIAL HWY STE 305
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1907
Practice Address - Country:US
Practice Address - Phone:703-359-8640
Practice Address - Fax:703-591-6105
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2021-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22398208D00000X
VA0101244015208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD651060400Medicaid
DC060320900Medicaid
VA1528039708Medicaid
VA176295ZAHMedicare UPIN
MD651060400Medicaid