Provider Demographics
NPI:1831343417
Name:MARK KANNZAWA, D.O., P.L.C.
Entity type:Organization
Organization Name:MARK KANNZAWA, D.O., P.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KANZAWA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-671-1753
Mailing Address - Street 1:23933 ALLEN RD
Mailing Address - Street 2:STE. 1
Mailing Address - City:WOODHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3372
Mailing Address - Country:US
Mailing Address - Phone:734-671-1753
Mailing Address - Fax:734-671-8130
Practice Address - Street 1:23933 ALLEN RD
Practice Address - Street 2:STE. 1
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-3372
Practice Address - Country:US
Practice Address - Phone:734-671-1753
Practice Address - Fax:734-671-8130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK0104802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI260042656OtherRR MEDICARE
MI5824919OtherBCBSM
MI4141722Medicaid
MI5824919OtherBCBSM
MI5824919Medicare PIN