=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306070172
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATIE R KWAK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2009
-----------------------------------------------------
Last Update Date | 11/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44428 WOODWARD AVE STE 102
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48341-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-858-3126
-----------------------------------------------------
Fax | 248-858-6499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44428 WOODWARD AVE STE 102
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48341-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-858-3126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 4301111118
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------