Provider Demographics
NPI:1457321184
Name:KODRIK, AMY (DO)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:KODRIK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28595 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2977
Mailing Address - Country:US
Mailing Address - Phone:248-553-0010
Mailing Address - Fax:248-553-5957
Practice Address - Street 1:28595 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2977
Practice Address - Country:US
Practice Address - Phone:248-553-0010
Practice Address - Fax:248-553-5957
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0150302084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4762823Medicaid
MII41545Medicare UPIN
MI4762823Medicaid