1982815288 NPI number — JESSE J KLEIN DO

Table of content: JESSE J KLEIN DO (NPI 1982815288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982815288 NPI number — JESSE J KLEIN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLEIN
Provider First Name:
JESSE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1982815288
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1345 W BAY DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LARGO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33770-2282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-581-3550
Provider Business Mailing Address Fax Number:
727-586-6190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1345 W BAY DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33770-2282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-581-3550
Provider Business Practice Location Address Fax Number:
727-586-6190
Provider Enumeration Date:
05/25/2007

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: 207RC0000X , with the licence number:  OS10628 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: OS 10628 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001094700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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