Provider Demographics
NPI:1487638771
Name:GLAZER-ZUCKER, MICHELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:GLAZER-ZUCKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 E 12 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2602
Mailing Address - Country:US
Mailing Address - Phone:248-399-6090
Mailing Address - Fax:248-399-5282
Practice Address - Street 1:1385 E 12 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2602
Practice Address - Country:US
Practice Address - Phone:248-399-6090
Practice Address - Fax:248-399-5282
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080190329OtherRR MEDICARE
MI1487638771Medicaid
MIF23754OtherHAP
MI700H273300OtherBLUE SHIELD
MIMI4989022Medicare PIN
MI1487638771Medicaid
MI1487638771Medicaid
MI080190329OtherRR MEDICARE