Provider Demographics
NPI:1073558029
Name:DEVRIES, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DEVRIES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26811 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-4075
Mailing Address - Country:US
Mailing Address - Phone:586-755-4433
Mailing Address - Fax:586-755-6655
Practice Address - Street 1:33200 DEQUINDRE RD STE 100
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5967
Practice Address - Country:US
Practice Address - Phone:586-354-1489
Practice Address - Fax:586-803-4289
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010495492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1366905408Medicaid