Provider Demographics
NPI:1942247689
Name:GULOW, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GULOW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13636 DIX TOLEDO RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2432
Mailing Address - Country:US
Mailing Address - Phone:734-283-2262
Mailing Address - Fax:
Practice Address - Street 1:30581 STEPHENSON HWY
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1610
Practice Address - Country:US
Practice Address - Phone:248-589-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008280207P00000X, 208D00000X, 207Q00000X
MI008280207PE0004X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1942247689Medicaid
MI113166549Medicaid
MIMG008280OtherBC/BS
MI112881665Medicaid
MI112881665Medicaid
E37581Medicare UPIN
MIM60660106Medicare PIN