1346358645 NPI number — MS. VIVIAN M KLOKE OD

Table of content: MS. VIVIAN M KLOKE OD (NPI 1346358645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346358645 NPI number — MS. VIVIAN M KLOKE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLOKE
Provider First Name:
VIVIAN
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346358645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
735 INSIGHT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O FALLON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62269-2193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-628-2903
Provider Business Mailing Address Fax Number:
618-628-2913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
735 INSIGHT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62269-2193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-628-2903
Provider Business Practice Location Address Fax Number:
618-628-2913
Provider Enumeration Date:
08/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046008375 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2202035 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1801926340 . This is a "TIN FOR OFFICE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 259903 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 08206037 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 046008375 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 400662 . This is a "GROUP HEALTH PLAN" identifier . This identifiers is of the category "OTHER".




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