Provider Demographics
NPI:1760476709
Name:KLETTER, IAN (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:KLETTER
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 1:30680 BAINBRIDGE RD
Mailing Address - Street 2:NORTHEAST OHIO GROUP PRACTICE
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44139-2282
Mailing Address - Country:US
Mailing Address - Phone:440-542-5023
Mailing Address - Fax:440-542-5029
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:ST JOHN WEST SHORE HOSPITAL
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5293
Practice Address - Country:US
Practice Address - Phone:440-835-8000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077854K208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2268559Medicaid
OHKL4052741Medicare ID - Type Unspecified
OH2268559Medicaid