Basic Information
Provider Information | |||||||||
NPI: | 1639380207 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLEVELAND | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | DUNCAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1227 N STATE ST | ||||||||
Address2: | SUITE 101 | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392022002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6013552485 | ||||||||
FaxNumber: | 6013531463 | ||||||||
Practice Location | |||||||||
Address1: | 2969 CURRAN DR N | ||||||||
Address2: | SUITE 200 | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392164121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6019745600 | ||||||||
FaxNumber: | 6019745699 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2007 | ||||||||
LastUpdateDate: | 04/27/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 17865 | MS | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 07334806 | 05 | MS |   | MEDICAID |