Provider Demographics
NPI:1427157197
Name:PEZDA, MARK FRANCIS (M D)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:FRANCIS
Last Name:PEZDA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21275 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:313-886-3217
Practice Address - Street 1:1977 E WATTLES RD
Practice Address - Street 2:UNIT G
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-5047
Practice Address - Country:US
Practice Address - Phone:248-528-3471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010383652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4569046Medicaid
MIB 48115Medicare UPIN
MI4569046Medicaid