Provider Demographics
NPI:1700873668
Name:KLIZEK, RONALD DALE (MD)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:DALE
Last Name:KLIZEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:15 S MAIN ST STE 250
Mailing Address - Street 2:P O BOX 788
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6627
Mailing Address - Country:US
Mailing Address - Phone:716-664-9731
Mailing Address - Fax:716-664-9160
Practice Address - Street 1:15 S MAIN ST STE 250
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6627
Practice Address - Country:US
Practice Address - Phone:716-664-9731
Practice Address - Fax:716-664-9160
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1446252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00706643Medicaid
NY144625OtherWORKERS COMPENSATION
NY300016615OtherRAILROAD MEDICARE
NY144625OtherWORKERS COMPENSATION
NY00706643Medicaid