Provider Demographics
NPI:1407086945
Name:KLEIN, HOLLY RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:RENEE
Last Name:KLEIN
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 1:14 CEDAR PARK DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-5203
Mailing Address - Country:US
Mailing Address - Phone:314-630-5272
Mailing Address - Fax:
Practice Address - Street 1:5915 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2710
Practice Address - Country:US
Practice Address - Phone:618-222-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009017119152W00000X
IL046010412152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMA1595032Medicare PIN