Provider Demographics
NPI:1487680856
Name:KLOTCH, DOUGLAS WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:KLOTCH
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 1:3450 E FLETCHER AVENUE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613
Mailing Address - Country:US
Mailing Address - Phone:813-977-1350
Mailing Address - Fax:813-977-1360
Practice Address - Street 1:3450 E FLETCHER AVENUE
Practice Address - Street 2:SUITE 260
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613
Practice Address - Country:US
Practice Address - Phone:813-977-1350
Practice Address - Fax:813-977-1360
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55312207Y00000X
NY1410211207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04545OtherBLUE CROSS BLUE SHIELD
FL04545OtherBLUE CROSS BLUE SHIELD
FL04545AMedicare ID - Type Unspecified