Provider Demographics
NPI:1255496170
Name:KLUTTS, FRED JR (OD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:KLUTTS
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6663
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:3910 HINKLEVILLE RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9017
Practice Address - Country:US
Practice Address - Phone:270-443-2090
Practice Address - Fax:270-444-2086
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0830DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77008308Medicaid
KY77008308Medicaid
KY0550202Medicare ID - Type UnspecifiedOD PIN