Provider Demographics
NPI:1275501421
Name:KLIBANOFF, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KLIBANOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-2053
Mailing Address - Country:US
Mailing Address - Phone:401-723-3400
Mailing Address - Fax:
Practice Address - Street 1:121 BROAD ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-2053
Practice Address - Country:US
Practice Address - Phone:401-723-3400
Practice Address - Fax:401-727-2326
Is Sole Proprietor?:No
Enumeration Date:2006-03-12
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007002355Medicare PIN