Provider Demographics
NPI:1922378454
Name:KLIETZ, MARK THOMAS (DVM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:KLIETZ
Suffix:
Gender:M
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E BROADWAY ST
Mailing Address - Street 2:STE. #7
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4970
Mailing Address - Country:US
Mailing Address - Phone:406-728-0095
Mailing Address - Fax:406-728-0097
Practice Address - Street 1:1001 E BROADWAY ST
Practice Address - Street 2:STE. #7
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4970
Practice Address - Country:US
Practice Address - Phone:406-728-0095
Practice Address - Fax:406-728-0097
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1297174M00000X
IL090.005719174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian