Healthcare Provider Details

I. General information

NPI: 1003842915
Provider Name (Legal Business Name): DAVID A KLOSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COUNTY ROAD B
SHAWANO WI
54166-7072
US

IV. Provider business mailing address

415 JEFFERSON ST NORTH TRI-COUNTY HOSPITAL
WADENA MN
56482-1296
US

V. Phone/Fax

Practice location:
  • Phone: 715-524-2161
  • Fax: 715-524-8164
Mailing address:
  • Phone: 218-631-3510
  • Fax: 218-631-7507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number68403
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number033503
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number54709
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: