Provider Demographics
NPI:1063584944
Name:KLEIN, GARY LLOYD (DPM)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LLOYD
Last Name:KLEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31201 CHICAGO RD S
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5527
Mailing Address - Country:US
Mailing Address - Phone:586-979-8811
Mailing Address - Fax:586-979-4794
Practice Address - Street 1:31201 CHICAGO RD S
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-5527
Practice Address - Country:US
Practice Address - Phone:586-979-8811
Practice Address - Fax:586-979-4794
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001655213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5635003Medicare PIN
MIU44812Medicare UPIN
MI1275370001Medicare NSC