Provider Demographics
NPI:1487696936
Name:KLENZAK, SCOTT M (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:KLENZAK
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 1:154 LINDEN PINES PL
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NC
Mailing Address - Zip Code:28315-5626
Mailing Address - Country:US
Mailing Address - Phone:910-585-2203
Mailing Address - Fax:910-692-3913
Practice Address - Street 1:250 N BENNETT ST
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-4811
Practice Address - Country:US
Practice Address - Phone:910-585-2203
Practice Address - Fax:910-692-3913
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97010122084P0800X, 2084F0202X, 2084P0804X
WV275852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902661Medicaid
NCG73380Medicare UPIN
NC5902661Medicaid