Provider Demographics
NPI:1356544100
Name:KLECKLEY, JOHN EDGAR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDGAR
Last Name:KLECKLEY
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 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:436-956-0718
Mailing Address - Fax:843-569-5879
Practice Address - Street 1:3710 LANDMARK DR STE 408
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4034
Practice Address - Country:US
Practice Address - Phone:803-799-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29749207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC297495Medicaid
SCP00467100OtherRAILROAD MEDICARE PIN
SCP00803393OtherRAILROAD MEDICARE ID-RSFPN
SCAA21659223Medicare PIN
SCAA21655551Medicare PIN
SCQ42123AMedicare PIN