Healthcare Provider Details

I. General information

NPI: 1659908903
Provider Name (Legal Business Name): MICAH Z BELZBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 THOMAS JOHNSON DR STE C
FREDERICK MD
21702-4893
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 240-780-3473
  • Fax: 240-880-3687
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD0102968
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberD0102968
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: