Provider Demographics
NPI:1669566436
Name:KLAPHOLZ, MARK BERNARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:BERNARD
Last Name:KLAPHOLZ
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 1:444 LAKEVILLE ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1165
Mailing Address - Country:US
Mailing Address - Phone:516-354-7660
Mailing Address - Fax:516-354-7671
Practice Address - Street 1:444 LAKEVILLE ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1165
Practice Address - Country:US
Practice Address - Phone:516-354-7660
Practice Address - Fax:516-354-7671
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143452207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAP016OtherOXFORD
NY0087865OtherGHI
B14231Medicare UPIN
NY0087865OtherGHI