Provider Demographics
NPI:1144545559
Name:KLEIBER BALDERRAMA, CRYSTAL J (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:J
Last Name:KLEIBER BALDERRAMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:J
Other - Last Name:KLEIBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:414-805-6851
Practice Address - Street 1:420 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8340
Practice Address - Fax:414-805-6851
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56510207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400093490Medicare PIN
WIK400093489Medicare PIN
WIK400093490Medicare PIN