Provider Demographics
NPI:1700966686
Name:MARK KLEBANOV MD CORP
Entity Type:Organization
Organization Name:MARK KLEBANOV MD CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEBANOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-296-0344
Mailing Address - Street 1:120 LA CASA VIA STE 102
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3092
Mailing Address - Country:US
Mailing Address - Phone:925-296-0344
Mailing Address - Fax:925-947-5424
Practice Address - Street 1:120 LA CASA VIA STE 102
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3092
Practice Address - Country:US
Practice Address - Phone:925-296-0344
Practice Address - Fax:925-947-5424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54480207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A544800Medicare ID - Type Unspecified
CAG24346Medicare UPIN