Provider Demographics
NPI:1235135260
Name:KLASS, MANDY A (MD)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:A
Last Name:KLASS
Suffix:
Gender:F
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 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:419-538-7330
Mailing Address - Fax:419-538-7331
Practice Address - Street 1:601 US 224
Practice Address - Street 2:SUITE 2
Practice Address - City:GLANDORF
Practice Address - State:OH
Practice Address - Zip Code:45848-0081
Practice Address - Country:US
Practice Address - Phone:419-538-7330
Practice Address - Fax:419-538-7331
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH083647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9364531OtherGROUP MEDICARE PIN
OH2986729Medicaid
OH9364531OtherGROUP MEDICARE PIN
OH2986729Medicaid