Provider Demographics
NPI:1417363268
Name:JANICE, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JANICE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6245 INKSTER RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-4001
Mailing Address - Country:US
Mailing Address - Phone:734-458-4486
Mailing Address - Fax:
Practice Address - Street 1:408 N HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5140
Practice Address - Country:US
Practice Address - Phone:432-580-7373
Practice Address - Fax:432-580-3275
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021147208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid