Basic Information
| Provider Information | |||||||||
| NPI: | 1740292069 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLEIN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4072455203 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4072455203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | ME93201 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 16049 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | ME93201 | 01 | FL | MEDICAL LICENSE | OTHER | 272517700 | 05 | FL | MEDICAID |