Healthcare Provider Details

I. General information

NPI: 1619531118
Provider Name (Legal Business Name): THEODORE JOSEPH KLIMEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 07/10/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 E LAKE ST
MINNEAPOLIS MN
55407-4385
US

IV. Provider business mailing address

2215 E LAKE ST
MINNEAPOLIS MN
55407-4385
US

V. Phone/Fax

Practice location:
  • Phone: 612-596-9438
  • Fax: 612-329-4500
Mailing address:
  • Phone: 612-596-9438
  • Fax: 612-329-4500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number73911
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: