Healthcare Provider Details

I. General information

NPI: 1013594514
Provider Name (Legal Business Name): CLEBERT ISMA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 HOUSTON RD
FLORENCE KY
41042-4824
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-8074
  • Fax: 859-301-4945
Mailing address:
  • Phone: 859-301-8074
  • Fax: 859-301-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01092982A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number59592
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number59592
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01092982A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: