Provider Demographics
NPI:1730612490
Name:DE KLERK, PIETER STORM (MD)
Entity type:Individual
Prefix:
First Name:PIETER
Middle Name:STORM
Last Name:DE KLERK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5891
Practice Address - Fax:401-444-8158
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-09
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD17152207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease