1164601167 NPI number — DR. MICHAEL D KLAUTZSCH OD

Table of content: DR. MICHAEL D KLAUTZSCH OD (NPI 1164601167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164601167 NPI number — DR. MICHAEL D KLAUTZSCH OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLAUTZSCH
Provider First Name:
MICHAEL
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1164601167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1810 SUMMER ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97301-7147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-364-0767
Provider Business Mailing Address Fax Number:
503-581-8340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 SUMMER ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-7147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-364-0767
Provider Business Practice Location Address Fax Number:
503-581-8340
Provider Enumeration Date:
10/26/2007

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: 152W00000X , with the licence number:  2515ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 079328000 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 079328001 . This is a "RBCBS MED ADVANTAGE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 074950 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 079327001 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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