Provider Demographics
NPI:1265162168
Name:KLOSOWSKI, DOMINIC
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:KLOSOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3443 FARR RD
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-8779
Mailing Address - Country:US
Mailing Address - Phone:231-672-2900
Mailing Address - Fax:
Practice Address - Street 1:3443 FARR RD
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-8779
Practice Address - Country:US
Practice Address - Phone:231-672-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351049991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine