Basic Information
| Provider Information | |||||||||
| NPI: | 1154518801 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ERIC J. KLOSTERMANN, D.P.M., A PROFESSIONAL CORPORATION | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3129 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905103129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107923914 | ||||||||
| FaxNumber: | 8558984055 | ||||||||
| Practice Location | |||||||||
| Address1: | 4560 ADMIRALTY WAY | ||||||||
| Address2: | SUITE 351 | ||||||||
| City: | MARINA DEL REY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902925423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107923914 | ||||||||
| FaxNumber: | 8558984055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 10/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | KLOSTERMANN | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3107923914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.P.M. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP1100X | E1993 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Podiatric |
ID Information
| ID | Type | State | Issuer | Description | 000E19930 | 01 | CA | BLUE SHIELD | OTHER | 000E19931 | 05 | CA | MEDICAID |