Basic Information
| Provider Information | |||||||||
| NPI: | 1922088293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLACIK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | JOHN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705353611 | ||||||||
| FaxNumber: | 7705357092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 054230 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 302581 | 01 | GA | WELLCARE | OTHER | 1908730 | 01 | GA | UHC | OTHER | 302568 | 01 | GA | WELLCARE | OTHER | 302579 | 01 | GA | WELLCARE | OTHER | 302580 | 01 | GA | WELLCARE | OTHER | 5779768 | 01 | GA | AETNA PPO | OTHER | 845371853C | 05 | GA | MEDICAID | 10032998 | 01 | GA | AMERIGROUP | OTHER | 3548885 | 01 | GA | CIGNA | OTHER | 845371853D | 05 | GA | MEDICAID | 845371853F | 05 | GA | MEDICAID | 52703273 | 01 | GA | BCBS | OTHER | 3532508 | 01 | GA | AETNA HMO | OTHER | 845371853A | 05 | GA | MEDICAID | 845371853B | 05 | GA | MEDICAID |