Provider Demographics
NPI:1346337110
Name:CHEPEHA, DOUGLAS B (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:B
Last Name:CHEPEHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:1ST FLOOR TAUBMAN CTR RECP A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5312
Practice Address - Country:US
Practice Address - Phone:734-936-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066532207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3183334Medicaid
MI3183334Medicaid
MIG19179Medicare UPIN