1487629655 NPI number — VONDA L KLEIN M.D.

Table of content: VONDA L KLEIN M.D. (NPI 1487629655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487629655 NPI number — VONDA L KLEIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLEIN
Provider First Name:
VONDA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROKOPP
Provider Other First Name:
VONDA
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487629655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
699 CHURCH ST NE
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30060-1116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-422-8505
Provider Business Mailing Address Fax Number:
770-424-7449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
699 CHURCH ST NE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30060-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-422-8505
Provider Business Practice Location Address Fax Number:
770-424-7449
Provider Enumeration Date:
02/21/2006

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: 207V00000X , with the licence number:  035826 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00659579D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0700105 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1331254-004 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 4486146 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 671722 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00659579E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00659579C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 323444 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10054024 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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