Provider Demographics
NPI:1154518801
Name:ERIC J. KLOSTERMANN, D.P.M., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:ERIC J. KLOSTERMANN, D.P.M., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLOSTERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-792-3914
Mailing Address - Street 1:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3129
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:4560 ADMIRALTY WAY
Practice Address - Street 2:SUITE 351
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5423
Practice Address - Country:US
Practice Address - Phone:310-792-3914
Practice Address - Fax:855-898-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1993261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E19930OtherBLUE SHIELD
CA000E19931Medicaid
CA5280900001Medicare NSC
CAW21362Medicare PIN
CAT11123Medicare UPIN