Provider Demographics
NPI:1154368165
Name:STIFF, MARK ALLYN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLYN
Last Name:STIFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26400 W 12 MILE RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1700
Mailing Address - Country:US
Mailing Address - Phone:248-355-5047
Mailing Address - Fax:248-355-3511
Practice Address - Street 1:26400 W 12 MILE RD
Practice Address - Street 2:SUITE 180
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1700
Practice Address - Country:US
Practice Address - Phone:248-355-5047
Practice Address - Fax:248-355-3511
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301052816207ND0101X, 207NS0135X, 207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3341836Medicaid
MIF07114Medicare UPIN
M34790001Medicare PIN