Provider Demographics
NPI:1871558569
Name:GUDZIAK, MARKO R (MD)
Entity type:Individual
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First Name:MARKO
Middle Name:R
Last Name:GUDZIAK
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Gender:M
Credentials:MD
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Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:44200 WOODWARD
Practice Address - Street 2:SUITE 207
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2981
Practice Address - Country:US
Practice Address - Phone:248-322-6103
Practice Address - Fax:248-322-6108
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2008-07-28
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Provider Licenses
StateLicense IDTaxonomies
MI4301063869208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5205588OtherAETNA
MI126142OtherPRIORITY HEALTH
MI0991683OtherHEALTH PLUS
MIF60397OtherHAP
MI340017337OtherRAILROAD MEDICARE
MI0605710001OtherCIGNA
MI340017337OtherRAILROAD MEDICARE
MI0605710001OtherCIGNA
MIF60397Medicare UPIN