Provider Demographics
NPI:1194720276
Name:GILDENBERG, STUART R (MD)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:R
Last Name:GILDENBERG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11900 E 12 MILE RD
Mailing Address - Street 2:STE 201
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3490
Mailing Address - Country:US
Mailing Address - Phone:586-574-2800
Mailing Address - Fax:586-574-2803
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:STE 201
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3490
Practice Address - Country:US
Practice Address - Phone:586-574-2800
Practice Address - Fax:586-574-2803
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-07-28
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Provider Licenses
StateLicense IDTaxonomies
MI4301407085207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI100784OtherMOLINA
MI1222960001OtherTOTAL HEALTH CARE
MIP00180380OtherTRAVELERS MEDICARE
MI070E15730OtherBCBSM
MISG407085OtherBLUE CARE NETWORK ADVANTA
MI1222960001OtherMIDWEST HEALTH PLAN
MI29183OtherCOMMUNITY CHOICE OF MICHI
MI4640517Medicaid
C3726OtherMCARE
MI070E015730OtherBCN ADVANTAGE
MI110028OtherCARER CHOICES
MI200330360OtherHEALTH PLUS OF MICHIGAN
MI4358234OtherAETNA
MI4358234OtherAETNA HMO
MI0N96970006OtherBCBSM MEDICARE PLUS BLUE
MI100962OtherGREAT LAKES HEALTH PLAN
MI110028OtherPREFERRED PLUS
MIF00397OtherHAP HMO