Provider Demographics
NPI:1255393377
Name:KLEIN, MARK JEFFERY (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JEFFERY
Last Name:KLEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR LBBY J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR RM 4012
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-572-1141
Practice Address - Fax:734-572-1142
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK001213213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0325980001Medicare NSC
MIT34166Medicare UPIN