Provider Demographics
NPI:1104879998
Name:KLETZ, JONATHAN MARK (DPM)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARK
Last Name:KLETZ
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 1:6760 ABRAMS RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0246
Mailing Address - Country:US
Mailing Address - Phone:214-340-8885
Mailing Address - Fax:214-340-4046
Practice Address - Street 1:6760 ABRAMS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0246
Practice Address - Country:US
Practice Address - Phone:214-340-8885
Practice Address - Fax:214-340-4046
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1102213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU02977Medicare UPIN
TX8F7539Medicare PIN
TX00G81CMedicare PIN
TX00T11AMedicare PIN