Provider Demographics
NPI:1760431175
Name:KALUZA, KARL NICHOLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:NICHOLAS
Last Name:KALUZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:200 NE MOTHER JOSEPH PL STE 210
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-3295
Mailing Address - Country:US
Mailing Address - Phone:360-254-6161
Mailing Address - Fax:360-449-1146
Practice Address - Street 1:4811 MEADOWS RD STE 101
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2542
Practice Address - Country:US
Practice Address - Phone:360-254-6161
Practice Address - Fax:360-449-1146
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORDO23861207QS0010X
MI5101015919207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR196161OtherMEDICARE PTAN
MIP32966FOtherBLUE CARE NETWORK
18666Medicare UPIN
MIN69170099Medicare PIN
MI7714607OtherAETNA/US HEALTHCARE
MI114849676Medicaid
MI0998889OtherHEALTHPLUS
MI114648945Medicaid