Provider Demographics
NPI:1457357006
Name:KLIN, MARIUSZ JERZY (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIUSZ
Middle Name:JERZY
Last Name:KLIN
Suffix:
Gender:M
Credentials:MD, PHD
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 452
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-0452
Mailing Address - Country:US
Mailing Address - Phone:850-215-7071
Mailing Address - Fax:850-215-7073
Practice Address - Street 1:2202 STATE AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7601
Practice Address - Country:US
Practice Address - Phone:850-215-7071
Practice Address - Fax:850-215-7073
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85851207RG0100X
CAA63234207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265270600Medicaid
FL51542OtherBLUE CROSS BLUE SHIELD FL
FL265270600Medicaid
FL51542OtherBLUE CROSS BLUE SHIELD FL