Provider Demographics
NPI:1376540286
Name:KACHADURIAN, MARK A (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:KACHADURIAN
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 1:27555 MIDDLEBELT RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5011
Mailing Address - Country:US
Mailing Address - Phone:248-478-5512
Mailing Address - Fax:248-478-5350
Practice Address - Street 1:27555 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5011
Practice Address - Country:US
Practice Address - Phone:248-478-5512
Practice Address - Fax:248-478-5350
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010102182084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3046952Medicaid
MIF80069Medicare UPIN