Provider Demographics
NPI:1720086523
Name:CLEVELAND, MARK GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GLENN
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1225 S GEAR AVE STE 252
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1687
Practice Address - Country:US
Practice Address - Phone:319-752-1805
Practice Address - Fax:319-752-1629
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA31130207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA421451292OtherTAX ID #
IA53739OtherBCBS OF IOWA
IA070008505OtherRAILROAD MEDICARE
IA31130OtherIA LICENSE #
IAI6570OtherMEDICARE GROUP #
IA16DO913344OtherCLIA #
IA0136119Medicaid
IABC3319868OtherDEA #
IABC3319868OtherDEA #
IA16DO913344OtherCLIA #