Provider Demographics
NPI:1164601167
Name:KLAUTZSCH, MICHAEL D (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:KLAUTZSCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2515ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR079328000OtherREGENCE BLUE CROSS
OR079328001OtherRBCBS MED ADVANTAGE
OR074950Medicaid
OR079327001OtherBLUE CROSS
OR079328001OtherRBCBS MED ADVANTAGE
ORU57220Medicare UPIN
OR4115630001Medicare NSC