Provider Demographics
NPI:1093737132
Name:KLEKOTKA, PAUL ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ALAN
Last Name:KLEKOTKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8123
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-2643
Mailing Address - Fax:314-454-5626
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:SUITE 5B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-2643
Practice Address - Fax:314-454-5626
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2006005515207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200925808Medicaid
MO200925808Medicaid
P00364912Medicare PIN
959980183Medicare PIN
MO200925808Medicaid