Provider Demographics
NPI:1811988504
Name:KITZMILLER, JOHN W (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:KITZMILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1455 S LAPEER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1468
Mailing Address - Country:US
Mailing Address - Phone:248-693-4000
Mailing Address - Fax:248-690-9361
Practice Address - Street 1:1455 S LAPEER RD STE 200
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1468
Practice Address - Country:US
Practice Address - Phone:248-693-4000
Practice Address - Fax:248-690-9361
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006731103T00000X
MI4301036695207QA0401X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1518393800Medicaid
MI1811988504Medicaid
0606301871OtherBCBS
0606301871OtherBCBS