Provider Demographics
NPI:1386737708
Name:LIDDELL, FELIX J (MD)
Entity type:Individual
Prefix:
First Name:FELIX
Middle Name:J
Last Name:LIDDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23088
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-0088
Mailing Address - Country:US
Mailing Address - Phone:313-538-8136
Mailing Address - Fax:313-538-8340
Practice Address - Street 1:18241 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-4176
Practice Address - Country:US
Practice Address - Phone:313-538-8136
Practice Address - Fax:313-538-8340
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027238207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
N67320006Medicare ID - Type Unspecified
MIB45015Medicare UPIN