Provider Demographics
NPI:1962404665
Name:KLOESEL, GREGORY B (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:B
Last Name:KLOESEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RIVER OAKS DR
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-562-2101
Mailing Address - Fax:817-562-2201
Practice Address - Street 1:101 RIVER OAKS DR
Practice Address - Street 2:STE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-562-2101
Practice Address - Fax:817-562-2201
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4107TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F9265OtherMEDICARE INDIVIDUAL PTAN
TX8F9265OtherMEDICARE INDIVIDUAL PTAN
TX8J9787Medicare Oscar/Certification
TX00Z898Medicare PIN
TX75-2970138OtherEIN
TX4717500001Medicare ID - Type UnspecifiedMEDICARE PALMETTO