Provider Demographics
NPI:1114975588
Name:KLIEGER, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:KLIEGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30997
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90030-0997
Mailing Address - Country:US
Mailing Address - Phone:559-455-4053
Mailing Address - Fax:559-455-4007
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-571-6622
Practice Address - Fax:209-527-2069
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0438772085R0202X
CAA1057932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02571424Medicaid
NYI05319Medicare UPIN
CTP00429275Medicare PIN
NYP00368182Medicare PIN
CTP00401959Medicare PIN
CT300003790Medicare PIN
NY02571424Medicaid
NY678T71Medicare PIN
CABF743ZMedicare PIN