Provider Demographics
NPI:1033220637
Name:KURIATA, MARK A (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:KURIATA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8516
Mailing Address - Country:US
Mailing Address - Phone:269-429-7546
Mailing Address - Fax:269-429-0807
Practice Address - Street 1:300 E MAIDEN LN
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8516
Practice Address - Country:US
Practice Address - Phone:269-429-7546
Practice Address - Fax:269-429-0807
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012454207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A10115OtherBCBSM GROUP
0751100205OtherBLUE CROSS
MI350460011Medicaid
MICG9582OtherPALMETTO GBA GROUP
MI1531892018OtherGROUP NPI
MI350460011Medicaid
0751100205OtherBLUE CROSS