1902029713 NPI number — E J DAROS DO PC

Table of content: (NPI 1902029713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902029713 NPI number — E J DAROS DO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
E J DAROS DO PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY DOCS CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902029713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8275 HOLLY RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-603-0990
Provider Business Mailing Address Fax Number:
810-603-1678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8275 HOLLY RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
GRAND BLANC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48439-2442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-603-0990
Provider Business Practice Location Address Fax Number:
810-603-1678
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAROS
Authorized Official First Name:
EVTISHIOS
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-603-0990

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ED007048 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1003800350 . This is a "NPI INDIVIDUAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4614320 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: ED007048 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080B511230 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: DM076048 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: $$$$$$$$$ . This is a "SSN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: AD013144 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1316944333 . This is a "NPI INDIVIDUAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1841284437 . This is a "NPI INDIVIDUAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: $$$$$$$$$ . This is a "SSN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2095522 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4613396 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: $$$$$$$$$ . This is a "SSN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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