Provider Demographics
NPI:1083799431
Name:KUZMA, MICAIAH MATTHEW (MD)
Entity Type:Individual
Prefix:MR
First Name:MICAIAH
Middle Name:MATTHEW
Last Name:KUZMA
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 1:2020 CAPITOL STREET NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:503-589-6240
Practice Address - Street 1:5900 INLAND SHORES WAY
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-589-6240
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR152066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500624513Medicaid
ORP00866340OtherRAILROAD MEDICARE
ORP00866340OtherRAILROAD MEDICARE
OR1228590002Medicare NSC