Provider Demographics
NPI:1205840691
Name:DANIEL, IRIS BOURBON (MD)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:BOURBON
Last Name:DANIEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRIS
Other - Middle Name:BOURBON
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:42490 GARFIELD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-263-7900
Mailing Address - Fax:586-263-0434
Practice Address - Street 1:42490 GARFIELD
Practice Address - Street 2:SUITE 207
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-263-7900
Practice Address - Fax:586-263-0434
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4301061948OtherLICENSE
MI4609956Medicaid
MI4609956Medicaid
G32018Medicare UPIN