Healthcare Provider Details

I. General information

NPI: 1578525374
Provider Name (Legal Business Name): MARK ETHAM KUZUCU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 NORTHWEST BLVD SUITE #202
COEUR D ALENE ID
83814-2974
US

IV. Provider business mailing address

250 NORTHWEST BLVD SUITE #202
COEUR D ALENE ID
83814-2974
US

V. Phone/Fax

Practice location:
  • Phone: 208-292-2263
  • Fax: 208-292-3130
Mailing address:
  • Phone: 208-292-2263
  • Fax: 208-292-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME90588
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: