Provider Demographics
NPI:1174517601
Name:KLOBERDANZ, DENNIS R (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:R
Last Name:KLOBERDANZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 E 30TH ST BLDG D
Mailing Address - Street 2:STE 101
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-327-1400
Mailing Address - Fax:505-327-3474
Practice Address - Street 1:2300 E 30TH ST BLDG D
Practice Address - Street 2:STE 101
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-327-1400
Practice Address - Fax:505-327-3474
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87-256207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM8060Medicaid
NM00NM001536OtherBCBS
NM87-256OtherNM LICENSE
NM87-256OtherNM LICENSE
C97892Medicare UPIN
NM8060Medicaid
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