Basic Information
| Provider Information | |||||||||
| NPI: | 1194792978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLODAS | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4010 W 65TH ST | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524567000 | ||||||||
| FaxNumber: | 9524567001 | ||||||||
| Practice Location | |||||||||
| Address1: | 6545 FRANCE AVENUE S. | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529295600 | ||||||||
| FaxNumber: | 9529295610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 32079 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 044217800 | 05 | MN | MEDICAID |