Provider Demographics
NPI:1053325589
Name:KLAASSEN, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:KLAASSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2310 CALIFORNIA ROAD
Mailing Address - Street 2:STE A
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-264-4163
Mailing Address - Fax:574-262-9650
Practice Address - Street 1:2310 CALIFORNIA ROAD
Practice Address - Street 2:STE A
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1228
Practice Address - Country:US
Practice Address - Phone:574-264-4163
Practice Address - Fax:574-262-9650
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01031923A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100206940AMedicaid
D95455Medicare UPIN
IN223420FMedicare ID - Type Unspecified