Provider Demographics
NPI:1215081211
Name:FENTON, FRANK L (DO)
Entity type:Individual
Prefix:DR
First Name:FRANK
Middle Name:L
Last Name:FENTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 S COMMERCE
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390
Mailing Address - Country:US
Mailing Address - Phone:248-624-1526
Mailing Address - Fax:248-624-9570
Practice Address - Street 1:2335 S COMMERCE
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390
Practice Address - Country:US
Practice Address - Phone:248-624-1526
Practice Address - Fax:248-624-9570
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFF007946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376304TYPEIIMedicaid
MI1376304TYPEIIMedicaid
F00494Medicare UPIN