Provider Demographics
NPI:1003943408
Name:CLARKSTON DERMATOLOGY & VEIN CENTER PLLC
Entity Type:Organization
Organization Name:CLARKSTON DERMATOLOGY & VEIN CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCFALDA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-620-3376
Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3198
Mailing Address - Country:US
Mailing Address - Phone:248-620-3376
Mailing Address - Fax:248-620-3379
Practice Address - Street 1:5701 BOW POINTE DR
Practice Address - Street 2:SUITE 215
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3198
Practice Address - Country:US
Practice Address - Phone:248-620-3376
Practice Address - Fax:248-620-3379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014699207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0756301335OtherBLUE CARE NETWORK
MI0P14750OtherMEDICARE PLUS BLUE
MIDD8092OtherMEDICARE RAILROAD
MI0756301335OtherBLUE CHOICE
MI0P14750OtherMEDICARE PLUS BLUE