Provider Demographics
NPI:1477676351
Name:KLIMACH, WALDEMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALDEMAR
Middle Name:
Last Name:KLIMACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6519
Mailing Address - Country:US
Mailing Address - Phone:928-716-6060
Mailing Address - Fax:
Practice Address - Street 1:3675 CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-6519
Practice Address - Country:US
Practice Address - Phone:928-716-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9501174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ224329OtherAHCCCS NUMBER
AZAZ0022410OtherARIZONA BLUE CROSS BLUE S
AZ0038552OtherHEALTHNET NUMBER
AZAZ0022410OtherARIZONA BLUE CROSS BLUE S