Healthcare Provider Details

I. General information

NPI: 1548363724
Provider Name (Legal Business Name): KLAAS J WIERENGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 10/08/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100296
GAINESVILLE FL
32610-0296
US

V. Phone/Fax

Practice location:
  • Phone: 352-627-9350
  • Fax:
Mailing address:
  • Phone: 352-294-5050
  • Fax: 352-294-8058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberME137139
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License NumberME137139
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number26999
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME137139
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: