Provider Demographics
NPI:1700438827
Name:PHILLIPS, CLEVELAND JR
Entity Type:Individual
Prefix:MR
First Name:CLEVELAND
Middle Name:
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11146 VANCE JACKSON RD APT 3801
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-2563
Mailing Address - Country:US
Mailing Address - Phone:210-332-5408
Mailing Address - Fax:
Practice Address - Street 1:11146 VANCE JACKSON RD APT 3801
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2563
Practice Address - Country:US
Practice Address - Phone:210-332-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization