Provider Demographics
NPI:1417576232
Name:TATOMIR, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:TATOMIR
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 1:6601 COLLEGE BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1504
Mailing Address - Country:US
Mailing Address - Phone:913-359-6001
Mailing Address - Fax:
Practice Address - Street 1:32401 8 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1301
Practice Address - Country:US
Practice Address - Phone:913-359-6001
Practice Address - Fax:913-359-5552
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-11
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151014255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine