Provider Demographics
NPI:1235193525
Name:FIVENSON, DAVID PAUL (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:PAUL
Last Name:FIVENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3200 W LIBERTY RD STE C5
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9746
Mailing Address - Country:US
Mailing Address - Phone:734-222-9630
Mailing Address - Fax:734-222-9631
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:734-222-9631
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI404817207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4425476Medicaid
MI4425476Medicaid
F01765Medicare UPIN