Provider Demographics
NPI:1770587164
Name:KLOBUTCHER, JEROME A (MD)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:A
Last Name:KLOBUTCHER
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 1:734 US HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-9514
Mailing Address - Country:US
Mailing Address - Phone:773-580-8971
Mailing Address - Fax:
Practice Address - Street 1:734 US HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-9514
Practice Address - Country:US
Practice Address - Phone:773-580-8971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061482174400000X
OH35.092769174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061482Medicaid
OHKL4257291Medicare PIN
IL036061482Medicaid
ILC39365Medicare UPIN
C39365Medicare UPIN