Provider Demographics
NPI:1306608948
Name:CLEGG, DANIEL KENNETH
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:KENNETH
Last Name:CLEGG
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 1:18803 WINDWARD WAY
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-7122
Mailing Address - Country:US
Mailing Address - Phone:330-671-1367
Mailing Address - Fax:
Practice Address - Street 1:5555 TRANSPORTATION BLVD
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-5371
Practice Address - Country:US
Practice Address - Phone:877-440-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.008631RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant