Provider Demographics
NPI:1649238817
Name:PANOZZO, KRISTEN FOLEY (DO)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:FOLEY
Last Name:PANOZZO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:K
Other - Last Name:FOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:11270 E 13 MILE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2599
Mailing Address - Country:US
Mailing Address - Phone:586-574-0630
Mailing Address - Fax:586-574-0636
Practice Address - Street 1:11270 E 13 MILE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2599
Practice Address - Country:US
Practice Address - Phone:586-574-0630
Practice Address - Fax:586-574-0636
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I53028Medicare UPIN
MIF36020120Medicare PIN
MI487560211Medicaid