Provider Demographics
NPI:1073741187
Name:MILOSE, JACLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:
Last Name:MILOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:18100 OAKWOOD BLVD STE 315
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4085
Practice Address - Country:US
Practice Address - Phone:313-271-0066
Practice Address - Fax:313-271-1047
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301117138208800000X
MI4301093876390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E06273OtherBCBSM
CB9133OtherRAILROAD MEDICARE