Provider Demographics
NPI:1639266406
Name:CLEVELAND, KENNETH E (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1190 NORTH STATE STREET
Mailing Address - Street 2:SUITE 502
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202
Mailing Address - Country:US
Mailing Address - Phone:601-944-1781
Mailing Address - Fax:601-353-0439
Practice Address - Street 1:1190 NORTH STATE STREET
Practice Address - Street 2:SUITE 502
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-944-1781
Practice Address - Fax:601-353-0439
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS15419208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123961Medicaid
MS00123961Medicaid