Provider Demographics
NPI:1194481457
Name:STURDIVANT, MARK A
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:STURDIVANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 W 117TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-1642
Mailing Address - Country:US
Mailing Address - Phone:216-417-4831
Mailing Address - Fax:
Practice Address - Street 1:2121 W 117TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-1642
Practice Address - Country:US
Practice Address - Phone:216-417-4831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002834175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0002834OtherPEER SUPPORT CERTIFICATION