Provider Demographics
NPI:1922088293
Name:KLACIK, STEPHEN JOHN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:KLACIK
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:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-535-3611
Practice Address - Fax:770-535-7092
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054230208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA302580OtherWELLCARE
GA10032998OtherAMERIGROUP
GA302568OtherWELLCARE
GA302579OtherWELLCARE
GA5779768OtherAETNA PPO
GA845371853DMedicaid
GA3548885OtherCIGNA
GA52703273OtherBCBS
GA845371853BMedicaid
GA3532508OtherAETNA HMO
GA845371853AMedicaid
GA1908730OtherUHC
GA845371853CMedicaid
GA302581OtherWELLCARE
GA845371853FMedicaid
GA845371853AMedicaid
GA302580OtherWELLCARE