Basic Information
| Provider Information | |||||||||
| NPI: | 1477139137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLUCHER | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 WALNUT VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722111837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019446229 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 S GREENE ST RM N3E09 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2021 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.