Provider Demographics
NPI:1003842915
Name:KLOSS, DAVID A (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:KLOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 JEFFERSON ST NORTH
Mailing Address - Street 2:TRI-COUNTY HOSPITAL
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1296
Mailing Address - Country:US
Mailing Address - Phone:218-631-3510
Mailing Address - Fax:218-631-7507
Practice Address - Street 1:100 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-7072
Practice Address - Country:US
Practice Address - Phone:715-524-2161
Practice Address - Fax:715-524-8164
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68403208600000X
CT033503174400000X
MN54709208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010033503CT01OtherANTHEM BC / BS
CT001335034Medicaid
CT0706347OtherAETNA / US HEALTHCARE
CT001335034OtherBLUE CARE FAMILY PLAN
CT335030OtherCONNECTICARE
CT1144213006OtherCIGNA
CTWIS020OtherOXFORD
CT030515OtherHEALTHNET
CTP02113OtherCHA
CT030515OtherHEALTHNET
CT0706347OtherAETNA / US HEALTHCARE
CTP02113OtherCHA
CTF73498Medicare UPIN