Provider Demographics
NPI:1700349495
Name:DE KLERK, KATHARINA ROSALINDE (DO)
Entity Type:Individual
Prefix:
First Name:KATHARINA
Middle Name:ROSALINDE
Last Name:DE KLERK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2770
Mailing Address - Country:US
Mailing Address - Phone:401-737-7010
Mailing Address - Fax:401-736-1975
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4474
Practice Address - Country:US
Practice Address - Phone:401-729-2961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RILP04632207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program