Provider Demographics
NPI:1154618122
Name:KAZAK, MARAT (DPM)
Entity type:Individual
Prefix:
First Name:MARAT
Middle Name:
Last Name:KAZAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 MERCY CT
Mailing Address - Street 2:150
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3158
Mailing Address - Country:US
Mailing Address - Phone:916-459-4398
Mailing Address - Fax:
Practice Address - Street 1:6600 MERCY CT
Practice Address - Street 2:#150
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3158
Practice Address - Country:US
Practice Address - Phone:916-459-4398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRESIDENT213ES0131X
CAE5117213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74-1612229OtherVA TIN
CACA128837Medicare UPIN