Provider Demographics
NPI:1487610721
Name:RUIZ, EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:RUIZ
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 1:51850 DEQUINDRE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-2806
Mailing Address - Country:US
Mailing Address - Phone:248-651-1010
Mailing Address - Fax:586-997-4279
Practice Address - Street 1:51850 DEQUINDRE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-2806
Practice Address - Country:US
Practice Address - Phone:248-651-1010
Practice Address - Fax:586-997-4279
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061025207N00000X
MIER061025207NS0135X, 207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104327804Medicaid
MI104327804Medicaid
0N30290Medicare ID - Type Unspecified