Provider Demographics
NPI:1215036140
Name:JEFFREY A KLOSTERMAN OPTOMETRIST INC
Entity Type:Organization
Organization Name:JEFFREY A KLOSTERMAN OPTOMETRIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KLOSTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:859-734-3697
Mailing Address - Street 1:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-0392
Mailing Address - Country:US
Mailing Address - Phone:859-734-3697
Mailing Address - Fax:859-734-3695
Practice Address - Street 1:101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-1633
Practice Address - Country:US
Practice Address - Phone:859-734-3697
Practice Address - Fax:859-734-3695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1674DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77001618Medicaid
KYDF5358Medicare PIN
KYV07131Medicare UPIN
KY77001618Medicaid