Basic Information
| Provider Information | |||||||||
| NPI: | 1619132792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLASKI | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | LEONARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 N LITCHFIELD RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853957830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235350050 | ||||||||
| FaxNumber: | 6235359520 | ||||||||
| Practice Location | |||||||||
| Address1: | 2940 N LITCHFIELD RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853957830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235350050 | ||||||||
| FaxNumber: | 6235359520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 06/20/2014 | ||||||||
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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 | 2084N0400X | R70154 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 698068 | 05 | AZ | MEDICAID |