Provider Demographics
NPI:1992793103
Name:KLEINHOFFER, JOHN WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:KLEINHOFFER
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 1:1312 MERCANTILE DR
Mailing Address - Street 2:WOODCREST PLAZA
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1240
Mailing Address - Country:US
Mailing Address - Phone:618-654-9999
Mailing Address - Fax:618-654-8430
Practice Address - Street 1:1312 MERCANTILE DR
Practice Address - Street 2:WOODCREST PLAZA
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1240
Practice Address - Country:US
Practice Address - Phone:618-654-9999
Practice Address - Fax:618-654-8430
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007969152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU47265Medicare UPIN
IL5426600001Medicare NSC
IL211845Medicare PIN
ILP00229381Medicare PIN