Provider Demographics
NPI:1104816065
Name:KLOCKE, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:KLOCKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 N BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-5102
Mailing Address - Country:US
Mailing Address - Phone:716-834-4522
Mailing Address - Fax:716-834-6191
Practice Address - Street 1:6000 N BAILEY AVE
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-5102
Practice Address - Country:US
Practice Address - Phone:716-834-4522
Practice Address - Fax:716-834-6191
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY182253208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040426001490OtherFIDELIS
NY00010092105OtherUNIVERA
NY01245578Medicaid
NY000511134005OtherBC/BS
NY1208952OtherIHA
NY143849DLOtherPREFERRED CARE
NY00010092105OtherUNIVERA
NYE91410Medicare UPIN