Provider Demographics
NPI:1992762413
Name:KLEINDORFER, MARK A (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:KLEINDORFER
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 1:1801 PONTOON RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-2338
Mailing Address - Country:US
Mailing Address - Phone:618-931-2700
Mailing Address - Fax:618-931-2747
Practice Address - Street 1:1801 PONTOON RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-2338
Practice Address - Country:US
Practice Address - Phone:618-931-2700
Practice Address - Fax:618-931-2747
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-7202152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046-7202OtherSTATE LICENSE
IL046-7202OtherSTATE LICENSE
ILMK0211487OtherDEA LICENSE
IL046-7202OtherSTATE LICENSE
IL0617010001Medicare NSC