Healthcare Provider Details

I. General information

NPI: 1609194588
Provider Name (Legal Business Name): MARY KATELIN KANOZA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY KATELIN ROBERTS MD

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 FAR HILLS AVE
KETTERING OH
45429-2405
US

IV. Provider business mailing address

4441 FAR HILLS AVE
KETTERING OH
45429-2405
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-7351
  • Fax: 937-298-9458
Mailing address:
  • Phone: 937-298-7351
  • Fax: 937-298-9458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35121178
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: