Provider Demographics
NPI:1306896352
Name:KALLUS, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:KALLUS
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:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-0307
Mailing Address - Country:US
Mailing Address - Phone:517-278-8861
Mailing Address - Fax:517-278-6053
Practice Address - Street 1:360 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2086
Practice Address - Country:US
Practice Address - Phone:517-278-8871
Practice Address - Fax:517-278-6053
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053693207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4396777Medicaid
MI4396777Medicaid
MI0N94620Medicare ID - Type Unspecified