Provider Demographics
NPI:1043203250
Name:KLIEFOTH, JAMES A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:KLIEFOTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PROFESSIONAL DR
Mailing Address - Street 2:STE 150
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5068
Mailing Address - Country:US
Mailing Address - Phone:618-463-8660
Mailing Address - Fax:618-463-8666
Practice Address - Street 1:1 PROFESSIONAL DR
Practice Address - Street 2:STE 150
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5068
Practice Address - Country:US
Practice Address - Phone:618-463-8660
Practice Address - Fax:618-463-8666
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051867208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK09770OtherPTAN
IL207219OtherGROUP PTAN
IL01606740682Medicaid
IL207219OtherGROUP PTAN