Provider Demographics
NPI:1114019627
Name:FOZO, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:FOZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:21000 E 12 MILE RD
Mailing Address - Street 2:STE 111
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081
Mailing Address - Country:US
Mailing Address - Phone:586-779-7610
Mailing Address - Fax:586-445-2523
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:SUITE 111
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1116
Practice Address - Country:US
Practice Address - Phone:586-779-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMF075562207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
4339229OtherAETNA
H68407OtherHEALTH ALLIANCE PLAN
0501379OtherBLUE CARE NETWORK
MI4505853Medicaid
136815OtherCARE CHOICES
P00014677OtherRAILROAD MEDICARE
141736OtherGREAT LAKES HEALTH PLAN
16056OtherMCAR
6029816OtherCIGNA
0501379OtherBLUE CARE NETWORK
16056OtherMCAR