Healthcare Provider Details

I. General information

NPI: 1861559627
Provider Name (Legal Business Name): MARTIN M. KLOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 MAIN ST SUITE 108
SPRINGFIELD OR
97478-5801
US

IV. Provider business mailing address

3831 MAIN STREET SUITE 108
SPRINGFIELD OR
97478-5801
US

V. Phone/Fax

Practice location:
  • Phone: 541-746-4468
  • Fax: 541-746-4562
Mailing address:
  • Phone: 541-746-4468
  • Fax: 541-746-4562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD18059
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License NumberMD18059
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: