Provider Demographics
NPI:1447478557
Name:KUIZON, SERVANDO R (MD)
Entity type:Individual
Prefix:
First Name:SERVANDO
Middle Name:R
Last Name:KUIZON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1143
Mailing Address - Country:US
Mailing Address - Phone:269-781-4271
Mailing Address - Fax:
Practice Address - Street 1:200 N MADISON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1143
Practice Address - Country:US
Practice Address - Phone:269-781-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010394112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08101313261Medicare ID - Type Unspecified
MIP04892Medicare UPIN