Healthcare Provider Details

I. General information

NPI: 1558570523
Provider Name (Legal Business Name): IVETTE E KLUMB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD SURGICAL SERVICE 112, 2A-180
RICHMOND VA
23249-0001
US

IV. Provider business mailing address

1201 BROAD ROCK BLVD SURGICAL SERVICE 112, 2A-180
RICHMOND VA
23249-0001
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-5112
  • Fax: 804-675-5390
Mailing address:
  • Phone: 804-675-5112
  • Fax: 804-675-5390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0101250058
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: