Basic Information
| Provider Information | |||||||||
| NPI: | 1720086523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEVELAND | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | GLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 S GEAR AVE STE 252 | ||||||||
| Address2: | |||||||||
| City: | WEST BURLINGTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 526551687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3197521805 | ||||||||
| FaxNumber: | 3197521629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 31130 | IA | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 31130 | IA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.