Provider Demographics
NPI:1083864243
Name:MICHAEL D KLAUTZSCH OD PC
Entity Type:Organization
Organization Name:MICHAEL D KLAUTZSCH OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:KLAUTZSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:5033-364-0767
Mailing Address - Street 1:1810 SUMMER ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7147
Mailing Address - Country:US
Mailing Address - Phone:503-364-0767
Mailing Address - Fax:503-581-8340
Practice Address - Street 1:1810 SUMMER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7147
Practice Address - Country:US
Practice Address - Phone:503-364-0767
Practice Address - Fax:503-581-8340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2515ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR4115630001Medicare NSC
ORR104768Medicare PIN