Provider Demographics
NPI:1558440628
Name:KEZLARIAN, KIM FORD (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:FORD
Last Name:KEZLARIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26300 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-0917
Mailing Address - Country:US
Mailing Address - Phone:245-546-2110
Mailing Address - Fax:248-546-8176
Practice Address - Street 1:26300 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0917
Practice Address - Country:US
Practice Address - Phone:245-546-2110
Practice Address - Fax:248-546-8176
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041887207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F32365OtherBCBS
MI104860996Medicaid
MI104860996Medicaid
MI0N95590001Medicare ID - Type Unspecified