Provider Demographics
NPI:1902074875
Name:ELLIOTT J. KLONSKY OD
Entity type:Organization
Organization Name:ELLIOTT J. KLONSKY OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KLONSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-721-2500
Mailing Address - Street 1:2225C DEFENSE HWY
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2403
Mailing Address - Country:US
Mailing Address - Phone:410-721-2500
Mailing Address - Fax:
Practice Address - Street 1:2225C DEFENSE HWY
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2403
Practice Address - Country:US
Practice Address - Phone:410-721-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTAO687332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0484680001Medicare NSC
MDX395Medicare PIN
MDT59950Medicare UPIN