Provider Demographics
NPI:1366611006
Name:JONATHAN M KLETZ DPM P A
Entity type:Organization
Organization Name:JONATHAN M KLETZ DPM P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:KLETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:214-340-8885
Mailing Address - Street 1:6760 ABRAMS RD
Mailing Address - Street 2:STE 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 1:514 E CORISICANA ST STE B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-2506
Practice Address - Country:US
Practice Address - Phone:909-677-9090
Practice Address - Fax:903-677-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1102213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120518901Medicaid
TX120518901Medicaid
TX4922850001Medicare NSC
TX00Y841Medicare PIN