Provider Demographics
NPI:1356494827
Name:NWAOPARA, BERTRAM N
Entity Type:Individual
Prefix:MR
First Name:BERTRAM
Middle Name:N
Last Name:NWAOPARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34741 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48335-3315
Mailing Address - Country:US
Mailing Address - Phone:248-471-4669
Mailing Address - Fax:248-471-4899
Practice Address - Street 1:34741 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48335-3315
Practice Address - Country:US
Practice Address - Phone:248-471-4669
Practice Address - Fax:248-471-4899
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5398880001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4693619 (OOV. TYPE 8Medicaid
MI821915 (PROCARE)OtherDURABLE MEDICAL EQUIPMENT
MI821915 (PROCARE)OtherDURABLE MEDICAL EQUIPMENT