Provider Demographics
NPI:1891775938
Name:DZIUBA, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:DZIUBA
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 1:24400 GREATER MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1340
Mailing Address - Country:US
Mailing Address - Phone:586-778-1881
Mailing Address - Fax:586-778-0667
Practice Address - Street 1:24400 GREATER MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1340
Practice Address - Country:US
Practice Address - Phone:586-778-1881
Practice Address - Fax:586-778-0667
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKD039122207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4157965Medicaid
MIP59280001Medicare PIN
MI0505614Medicare PIN
MIA74419Medicare UPIN
MI110064510Medicare PIN