Provider Demographics
NPI:1134462161
Name:KLOCEK, MATTHEW S (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:KLOCEK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 ROUTE 4 STE 202
Mailing Address - Street 2:
Mailing Address - City:SINAJANA
Mailing Address - State:GU
Mailing Address - Zip Code:96910-3368
Mailing Address - Country:US
Mailing Address - Phone:671-989-4747
Mailing Address - Fax:671-989-4743
Practice Address - Street 1:736 ROUTE 4 STE 202
Practice Address - Street 2:
Practice Address - City:SINAJANA
Practice Address - State:GU
Practice Address - Zip Code:96910-3368
Practice Address - Country:US
Practice Address - Phone:671-989-4747
Practice Address - Fax:671-989-4743
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMRS2016-0346390200000X
GUM-2201207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program