Provider Demographics
NPI:1427364157
Name:KLIBANOFF, MONA (OD)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:KLIBANOFF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:
Other - Last Name:AOUDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:55 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-2023
Mailing Address - Country:US
Mailing Address - Phone:401-723-3400
Mailing Address - Fax:401-727-2326
Practice Address - Street 1:55 BROAD ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-2023
Practice Address - Country:US
Practice Address - Phone:401-723-3400
Practice Address - Fax:401-727-2326
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4817152W00000X
RIODTG00553152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI002086302Medicare PIN