Provider Demographics
NPI:1689680886
Name:KLINE, MICHAEL WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WALTER
Last Name:KLINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 RUSTY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-1973
Mailing Address - Country:US
Mailing Address - Phone:314-894-7951
Mailing Address - Fax:314-894-7977
Practice Address - Street 1:4200 RUSTY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-1973
Practice Address - Country:US
Practice Address - Phone:314-894-7951
Practice Address - Fax:314-894-7977
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2012-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007659152W00000X
GAOPT002155152W00000X
MO2012011384152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist