Provider Demographics
NPI:1063702876
Name:KLEM, THEODORE CARROLL (MD)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:CARROLL
Last Name:KLEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9433 BEE CAVES RD
Mailing Address - Street 2:BUILDING 3, SUITE 103
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78733
Mailing Address - Country:US
Mailing Address - Phone:512-649-7515
Mailing Address - Fax:512-649-1913
Practice Address - Street 1:9433 BEE CAVES RD
Practice Address - Street 2:BUILDING 3, SUITE 103
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78733
Practice Address - Country:US
Practice Address - Phone:512-649-7515
Practice Address - Fax:512-649-1913
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD23168207R00000X
TXQ0485207R00000X
TXBP10039985207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX375277YLP1OtherMEDICARE PTAN
TX375277YKXVOtherMEDICARE PTAN
TX375277YLP2OtherMEDICARE PTAN
TX375277YKXYOtherMEDICARE PTAN