Provider Demographics
NPI:1972521623
Name:KLETZ, MICHAEL R (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:KLETZ
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 1:1420 SPRING HILL RD STE 350
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3040
Mailing Address - Country:US
Mailing Address - Phone:703-790-9722
Mailing Address - Fax:703-893-8666
Practice Address - Street 1:1420 SPRING HILL RD
Practice Address - Street 2:SUITE 350
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3006
Practice Address - Country:US
Practice Address - Phone:703-790-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043722174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
030002414OtherRAILROAD MEDICARE
VA6023312Medicaid
VA6023312Medicaid
E40051Medicare UPIN
DC597615Y78Medicare PIN