Provider Demographics
NPI:1205037454
Name:DAVID FIVENSON, M.D.DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:DAVID FIVENSON, M.D.DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FIVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-222-9630
Mailing Address - Street 1:3001 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-2122
Mailing Address - Country:US
Mailing Address - Phone:734-222-9630
Mailing Address - Fax:
Practice Address - Street 1:3001 MILLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2122
Practice Address - Country:US
Practice Address - Phone:734-222-9630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDF404817207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDF404817OtherSTATE LICENSE
MIDF404817OtherSTATE LICENSE