Healthcare Provider Details

I. General information

NPI: 1710219225
Provider Name (Legal Business Name): JESSE M. NIEDERKLEIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MT. CARMEL WAY
PITSBURG KS
66762
US

IV. Provider business mailing address

1 MT CARMEL WAY
PITTSBURG KS
66762-7587
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-6100
  • Fax: 620-231-0081
Mailing address:
  • Phone: 620-231-7600
  • Fax: 620-231-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4543
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4543
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: