1053325589 NPI number — MARK A KLAASSEN MD

Table of content: MARK A KLAASSEN MD (NPI 1053325589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053325589 NPI number — MARK A KLAASSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLAASSEN
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1053325589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5052 N CLINTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-5822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-484-8551
Provider Business Mailing Address Fax Number:
260-482-5060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 EAST 200 NORTH
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
WARSAW
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-264-4163
Provider Business Practice Location Address Fax Number:
574-262-9650
Provider Enumeration Date:
07/28/2006

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: 207X00000X , with the licence number:  01031923A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100206940A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com