Provider Demographics
NPI:1912066622
Name:KLEINERT, JOHN KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEITH
Last Name:KLEINERT
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 1:366 HWY 441 BYPASS
Mailing Address - Street 2:PO BOX 26
Mailing Address - City:BALDWIN
Mailing Address - State:GA
Mailing Address - Zip Code:30511
Mailing Address - Country:US
Mailing Address - Phone:706-776-1403
Mailing Address - Fax:
Practice Address - Street 1:366 HIGHWAY 441 BYPASS
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:GA
Practice Address - Zip Code:30511-1807
Practice Address - Country:US
Practice Address - Phone:706-776-1403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1107152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCBPNMedicare ID - Type Unspecified
GAU12504Medicare UPIN