Provider Demographics
NPI:1366465528
Name:PROUGH, DAVID PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PAUL
Last Name:PROUGH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1100 E MICHIGAN AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201
Mailing Address - Country:US
Mailing Address - Phone:517-782-5857
Mailing Address - Fax:517-784-3237
Practice Address - Street 1:1100 E MICHIGAN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201
Practice Address - Country:US
Practice Address - Phone:517-782-5857
Practice Address - Fax:517-784-3237
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-06-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301407188208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102754330Medicaid
E90775Medicare UPIN
0380056Medicare ID - Type Unspecified