Provider Demographics
NPI:1104865633
Name:DINVERNO, JOEL BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:BENJAMIN
Last Name:DINVERNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11755 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9219
Mailing Address - Country:US
Mailing Address - Phone:517-522-6100
Mailing Address - Fax:517-522-4715
Practice Address - Street 1:11755 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9219
Practice Address - Country:US
Practice Address - Phone:517-522-6100
Practice Address - Fax:517-522-4715
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073676208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3503810581OtherBCBS
MI104717265Medicaid
MI3503810581OtherBCBS