Provider Demographics
NPI:1760539803
Name:BEROZA, KENNETH WALTER (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WALTER
Last Name:BEROZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 336
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48804
Mailing Address - Country:US
Mailing Address - Phone:989-773-5095
Mailing Address - Fax:989-772-2827
Practice Address - Street 1:1021 S KINNEY STREET
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-773-5095
Practice Address - Fax:989-772-2827
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010547432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301054743OtherMEDICINE PERMANENT ID