Provider Demographics
NPI:1184629180
Name:LODER, BRIAN GEORGE (DPM, CWS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GEORGE
Last Name:LODER
Suffix:
Gender:M
Credentials:DPM, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15760 19 MILE RD STE E
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6319
Mailing Address - Country:US
Mailing Address - Phone:586-329-3895
Mailing Address - Fax:586-329-3916
Practice Address - Street 1:43391 COMMONS DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1109
Practice Address - Country:US
Practice Address - Phone:586-329-3895
Practice Address - Fax:586-329-3916
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBL001662213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10040760007OtherWELLNESS
MI4855057230OtherBLUE CARE NETWORK
MI4616745Medicaid
MIC3980OtherMCARE
MIP00777182OtherRAILROAD MEDICARE
MI101706OtherGREAT LAKES HEALTH PLAN
MI107320OtherPREFERRED/CARE CHOICES
MIU53759OtherHEALTH ALLIANCE PLAN
MI234010003OtherCIGNA
MI4616745OtherMOLINA
MI4638660OtherAETNA
MI4855057230OtherBLUE CROSS BLUE SHIELD MI
MI234010003OtherCIGNA
MIU53759Medicare UPIN
MIMI1640001Medicare PIN
MI10040760007OtherWELLNESS
MI4855057230OtherBLUE CROSS BLUE SHIELD MI