Provider Demographics
NPI:1063676310
Name:KLEINMAN, MARK ELLSWORTH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ELLSWORTH
Last Name:KLEINMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:320 PROSPERITY DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4709
Mailing Address - Country:US
Mailing Address - Phone:423-756-1512
Mailing Address - Fax:
Practice Address - Street 1:2412 N JOHN B DENNIS HWY
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4772
Practice Address - Country:US
Practice Address - Phone:423-578-4364
Practice Address - Fax:423-578-4372
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44136207W00000X, 207WX0107X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100169870Medicaid
KYK014442Medicare PIN
KYK014440Medicare PIN