Provider Demographics
NPI:1225098981
Name:KLANCKE, KIM ARLAN (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ARLAN
Last Name:KLANCKE
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 1:695 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114
Mailing Address - Country:US
Mailing Address - Phone:386-258-8722
Mailing Address - Fax:386-258-8659
Practice Address - Street 1:655 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2321
Practice Address - Country:US
Practice Address - Phone:386-258-8722
Practice Address - Fax:386-258-8659
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0039807207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068030300Medicaid
FL64479OtherBC BS
FL64479OtherBC BS
FL068030300Medicaid
FL64479ZMedicare PIN