Provider Demographics
NPI:1346358645
Name:KLOKE, VIVIAN M (OD)
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:M
Last Name:KLOKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 INSIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2193
Mailing Address - Country:US
Mailing Address - Phone:618-628-2903
Mailing Address - Fax:618-628-2913
Practice Address - Street 1:735 INSIGHT AVE
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2193
Practice Address - Country:US
Practice Address - Phone:618-628-2903
Practice Address - Fax:618-628-2913
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2202035OtherUNITED HEALTHCARE
IL1801926340OtherTIN FOR OFFICE
IL259903OtherHEALTHLINK
IL08206037OtherBCBS
IL046008375Medicaid
400662OtherGROUP HEALTH PLAN
2202035OtherUNITED HEALTHCARE
IL203881Medicare PIN
IL4714610001Medicare PIN
ILP00003344Medicare PIN
IL08206037OtherBCBS