Healthcare Provider Details

I. General information

NPI: 1568490910
Provider Name (Legal Business Name): GARY J KLEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 N CIRCLE DR #200
COLORADO SPGS CO
80909-1163
US

IV. Provider business mailing address

2960 N CIRCLE DR #200
COLORADO SPGS CO
80909-1163
US

V. Phone/Fax

Practice location:
  • Phone: 719-634-8891
  • Fax: 719-634-1897
Mailing address:
  • Phone: 719-634-8891
  • Fax: 719-634-1897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30107
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: