Provider Demographics
NPI:1316931405
Name:PROVIZER, JEFFREY LOUIS (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LOUIS
Last Name:PROVIZER
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 1:29992 NORTHWESTERN HWY STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3292
Mailing Address - Country:US
Mailing Address - Phone:248-851-1430
Mailing Address - Fax:248-851-5182
Practice Address - Street 1:32255 NORTHWESTERN HWY STE 130
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334
Practice Address - Country:US
Practice Address - Phone:248-723-5880
Practice Address - Fax:248-723-5889
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316931405Medicaid
MION30580003Medicare ID - Type Unspecified
MI4431375Medicaid