Provider Demographics
NPI:1861784340
Name:TREVINO, MANDY LYNN (MD)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:LYNN
Last Name:TREVINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:
Practice Address - Street 1:3045 GRANGE HALL RD
Practice Address - Street 2:STE 7
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1020
Practice Address - Country:US
Practice Address - Phone:248-627-4978
Practice Address - Fax:248-627-4927
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301099014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN83650007Medicare PIN