Provider Demographics
NPI:1265482095
Name:KURZAWA, MARK ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:KURZAWA
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 1:43750 GARFIELD RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1135
Mailing Address - Country:US
Mailing Address - Phone:586-226-6865
Mailing Address - Fax:586-226-6880
Practice Address - Street 1:36367 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-2958
Practice Address - Country:US
Practice Address - Phone:586-791-6868
Practice Address - Fax:586-791-5071
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048125207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4813978Medicaid
MI4991915Medicaid
MI4991915Medicaid
MI4813978Medicaid