Provider Demographics
NPI:1922065010
Name:KLINGBERG, KATHRYN M (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:KLINGBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14655 GALAXIE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-8575
Mailing Address - Country:US
Mailing Address - Phone:952-432-6161
Mailing Address - Fax:
Practice Address - Street 1:14655 GALAXIE AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-8575
Practice Address - Country:US
Practice Address - Phone:952-432-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41653207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN927018300Medicaid
080013818Medicare ID - Type Unspecified
H00850Medicare UPIN