Provider Demographics
NPI:1700914041
Name:KLINDWORTH, MICHAEL R (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:KLINDWORTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-2253
Mailing Address - Country:US
Mailing Address - Phone:360-653-3498
Mailing Address - Fax:360-659-0514
Practice Address - Street 1:9925 STATE AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-2253
Practice Address - Country:US
Practice Address - Phone:360-653-3498
Practice Address - Fax:360-659-0514
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA 3220 TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist