Provider Demographics
NPI:1922037779
Name:DVORAK, KATHLEEN MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:DVORAK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 HOGBACK RD STE 7
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9752
Mailing Address - Country:US
Mailing Address - Phone:734-677-1900
Mailing Address - Fax:734-677-0830
Practice Address - Street 1:2020 HOGBACK RD STE 7
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9752
Practice Address - Country:US
Practice Address - Phone:734-677-1900
Practice Address - Fax:734-677-0830
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKD005488111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKD005488OtherSTATE LICENSE #
MI0N90280Medicare ID - Type UnspecifiedMEDICARE BUISSNESS #
MIU32633Medicare UPIN
MIN90280002Medicare PIN