Healthcare Provider Details

I. General information

NPI: 1295350692
Provider Name (Legal Business Name): HENRY KOZDRON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

684 N PORT CRESCENT ST
BAD AXE MI
48413-1275
US

IV. Provider business mailing address

684 N PORT CRESCENT ST
BAD AXE MI
48413-1275
US

V. Phone/Fax

Practice location:
  • Phone: 989-912-6575
  • Fax: 989-912-6013
Mailing address:
  • Phone: 989-912-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5151014202
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5151014202
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101027382
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: