Provider Demographics
NPI:1609194588
Name:KANOZA, MARY KATELIN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATELIN
Last Name:KANOZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATELIN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4441 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2405
Mailing Address - Country:US
Mailing Address - Phone:937-298-7351
Mailing Address - Fax:937-298-9458
Practice Address - Street 1:4441 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2405
Practice Address - Country:US
Practice Address - Phone:937-298-7351
Practice Address - Fax:937-298-9458
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35121178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0084532Medicaid
OHH199631Medicare PIN
OH0084532Medicaid