Healthcare Provider Details

I. General information

NPI: 1023677812
Provider Name (Legal Business Name): JACK KLENDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 COLUMBIA DR
JOHNSON CITY NY
13790-3300
US

IV. Provider business mailing address

125 KENNEDY DR STE 400
HAUPPAUGE NY
11788-4017
US

V. Phone/Fax

Practice location:
  • Phone: 855-295-4144
  • Fax: 631-257-5097
Mailing address:
  • Phone: 855-295-4144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number339152
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number94-09970
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: