Provider Demographics
NPI:1053347468
Name:KLODELL, CHARLES T JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:T
Last Name:KLODELL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:THOMAS
Other - Last Name:KLODELL
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6440 W NEWBERRY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4381
Mailing Address - Country:US
Mailing Address - Phone:352-333-5610
Mailing Address - Fax:352-333-5611
Practice Address - Street 1:6440 W NEWBERRY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4381
Practice Address - Country:US
Practice Address - Phone:352-333-5610
Practice Address - Fax:352-333-5611
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85194208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265166100Medicaid
FL265166100Medicaid
FL17065ZMedicare PIN
FL265166100Medicaid