Healthcare Provider Details

I. General information

NPI: 1063468288
Provider Name (Legal Business Name): JUSTIN FRANK KLAMERUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N OTSEGO AVE
GAYLORD MI
49735-1558
US

IV. Provider business mailing address

416 CONNABLE AVE
PETOSKEY MI
49770-2212
US

V. Phone/Fax

Practice location:
  • Phone: 989-731-7760
  • Fax:
Mailing address:
  • Phone: 231-487-7129
  • Fax: 231-487-3082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number4301095357
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: