Provider Demographics
NPI:1417915240
Name:KLAK, KENNETH J (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:KLAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 ROCKSIDE RD
Mailing Address - Street 2:314
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-2774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1440 ROCKSIDE RD
Practice Address - Street 2:314
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-2774
Practice Address - Country:US
Practice Address - Phone:440-799-4433
Practice Address - Fax:440-799-4437
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002229207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0938696Medicaid