Basic Information
| Provider Information | |||||||||
| NPI: | 1114975588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLIEGER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30997 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900300997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554053 | ||||||||
| FaxNumber: | 5594554007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 MCHENRY AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095716622 | ||||||||
| FaxNumber: | 2095272069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 01/27/2009 | ||||||||
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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 | 2085R0202X | 043877 | CT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | A105793 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02571424 | 05 | NY | MEDICAID |