Basic Information
| Provider Information | |||||||||
| NPI: | 1740284660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAZMIN | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 E HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | WILLARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448901611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199645000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 E HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | WILLARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448901611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199331333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35-02-4483K | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0213165 | 05 | OH | MEDICAID |