Provider Demographics
NPI:1194780213
Name:KLEIN, JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:KLEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10033 CONWAY
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124
Mailing Address - Country:US
Mailing Address - Phone:314-432-1717
Mailing Address - Fax:
Practice Address - Street 1:3009 NORTH BALLAS ROAD
Practice Address - Street 2:SUITE 366 C
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-569-2424
Practice Address - Fax:314-569-2158
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5252207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A10979Medicare UPIN
M6788Medicare ID - Type Unspecified