Healthcare Provider Details

I. General information

NPI: 1659380939
Provider Name (Legal Business Name): MARKIAN R IWASZKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVE SE STE 230
GRAND RAPIDS MI
49546-3680
US

IV. Provider business mailing address

1000 E PARIS AVE SE STE 230
GRAND RAPIDS MI
49546-3680
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-4340
  • Fax: 616-949-4341
Mailing address:
  • Phone: 616-949-4340
  • Fax: 616-949-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01089840A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301095939
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: