Provider Demographics
NPI:1942564802
Name:KLECKA, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:KLECKA
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 1:26908 DETROIT RD
Mailing Address - Street 2:STE. 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-892-6406
Mailing Address - Fax:440-617-0884
Practice Address - Street 1:26908 DETROIT RD
Practice Address - Street 2:STE. 200
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2398
Practice Address - Country:US
Practice Address - Phone:440-250-8660
Practice Address - Fax:440-250-8639
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56604207R00000X
OH35.127125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0152379Medicaid
OHH466441Medicare PIN