Provider Demographics
NPI:1326036849
Name:FLAKE, THOMAS M JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:FLAKE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:23077 GREENFIELD RD.
Mailing Address - Street 2:SUITE 445
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-569-5407
Mailing Address - Fax:248-569-5594
Practice Address - Street 1:23077 GREENFIELD RD
Practice Address - Street 2:SUITE 445
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3709
Practice Address - Country:US
Practice Address - Phone:248-569-5407
Practice Address - Fax:248-569-5594
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2007-10-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301043819208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB46122Medicare UPIN
MI0N33040Medicare PIN