Healthcare Provider Details

I. General information

NPI: 1790989671
Provider Name (Legal Business Name): ANN M KLEDZIK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 BARNHILL DR #4300
INDIANAPOLIS IN
46202-5128
US

IV. Provider business mailing address

702 BARNHILL DR #4300
INDIANAPOLIS IN
46202-5128
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-8162
  • Fax:
Mailing address:
  • Phone: 317-274-8162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number11012166A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number01065931A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: