Provider Demographics
NPI:1083065916
Name:KATHAWA, JOLIAN SAM (DO)
Entity Type:Individual
Prefix:
First Name:JOLIAN
Middle Name:SAM
Last Name:KATHAWA
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 1:23133 ORCHARD LAKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3279
Mailing Address - Country:US
Mailing Address - Phone:248-579-9220
Mailing Address - Fax:248-471-9978
Practice Address - Street 1:23133 ORCHARD LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3279
Practice Address - Country:US
Practice Address - Phone:248-579-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022774207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology