Basic Information
| Provider Information | |||||||||
| NPI: | 1225444516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLEAVE | ||||||||
| FirstName: | TAHARKA | ||||||||
| MiddleName: | KINGO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 CLARKSON AVE | ||||||||
| Address2: | BOX 1228 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182453318 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 450 CLARKSON AVE | ||||||||
| Address2: | BOX 1228 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182453318 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2014 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 21037 | NH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 25MB10861600 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 304303 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.