Basic Information
Provider Information | |||||||||
NPI: | 1144545559 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KLEIBER BALDERRAMA | ||||||||
FirstName: | CRYSTAL | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KLEIBER | ||||||||
OtherFirstName: | CRYSTAL | ||||||||
OtherMiddleName: | J. | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 420 E DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | FOND DU LAC | ||||||||
State: | WI | ||||||||
PostalCode: | 549354560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209268340 | ||||||||
FaxNumber: | 4148056851 | ||||||||
Practice Location | |||||||||
Address1: | 420 E DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | FOND DU LAC | ||||||||
State: | WI | ||||||||
PostalCode: | 549354560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209268340 | ||||||||
FaxNumber: | 4148056851 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2010 | ||||||||
LastUpdateDate: | 10/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 56510 | WI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RR0500X | 56510 | WI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
No ID Information.