Healthcare Provider Details

I. General information

NPI: 1053404756
Provider Name (Legal Business Name): JOHN F KLUDT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGHWAY 12
HETTINGER ND
58639
US

IV. Provider business mailing address

1100 HIGHWAY 12
HETTINGER ND
58639-7533
US

V. Phone/Fax

Practice location:
  • Phone: 701-567-6133
  • Fax:
Mailing address:
  • Phone: 701-567-6130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0504
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: