Facts
- Status
- A
- Credential
- MD
- Type
- Individual
- Enumeration date
- 2017-06-27
- Last updated
- 2025-07-16
Specialties
Licenses
- License MI
- 4301513624
Location
- Practice location
- 1216 RICHARDSON ST
- City
- PORT HURON MI
- Postal code
- 480603549
- Phone
- 810-985-2620
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.