Healthcare Provider Details

I. General information

NPI: 1114019627
Provider Name (Legal Business Name): MICHAEL S FOZO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 E 12 MILE RD SUITE 111
SAINT CLAIR SHORES MI
48081-1116
US

IV. Provider business mailing address

21000 E 12 MILE RD STE 111
ST CLAIR SHORES MI
48081
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-7610
  • Fax:
Mailing address:
  • Phone: 586-779-7610
  • Fax: 586-445-2523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberMF075562
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: