Basic Information
Provider Information | |||||||||
NPI: | 1912919598 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLEAVER | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6751 N 72ND ST | ||||||||
Address2: | SUITE 105 | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681221746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4025722020 | ||||||||
FaxNumber: | 4025722150 | ||||||||
Practice Location | |||||||||
Address1: | 6751 N 72ND ST | ||||||||
Address2: | SUITE 105 | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681221746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4025722020 | ||||||||
FaxNumber: | 4025722150 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1229 | NE | Y |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | 02319 | IA | N |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 245098 | 01 | NE | MIDLANDS CHOICE | OTHER | 239105 | 01 | NE | COVENTRY | OTHER | 37061 | 01 | NE | BCBS NE | OTHER | 47067295013 | 05 | NE |   | MEDICAID | 93682 | 01 | IA | BCBS IA | OTHER | 0595835 | 05 | IA |   | MEDICAID |