Provider Demographics
NPI:1821044231
Name:KLOSTERMANN, KEVIN J (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:KLOSTERMANN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6653 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5906
Mailing Address - Country:US
Mailing Address - Phone:716-204-4500
Mailing Address - Fax:716-204-4501
Practice Address - Street 1:565 ABBOTT RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-2039
Practice Address - Country:US
Practice Address - Phone:716-204-4500
Practice Address - Fax:716-204-4501
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008140-1207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02166154Medicaid
NY02166154Medicaid