Provider Demographics
NPI:1235172537
Name:KOCHKODAN, JAMES J (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:KOCHKODAN
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:PO BOX 2802
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48123-2929
Mailing Address - Country:US
Mailing Address - Phone:313-359-7650
Mailing Address - Fax:313-359-7660
Practice Address - Street 1:840 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2319
Practice Address - Country:US
Practice Address - Phone:313-359-7650
Practice Address - Fax:313-359-7660
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010479102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1897437Medicaid
MIH26272023Medicare PIN
A78480Medicare UPIN
MI1897437Medicaid