Provider Demographics
NPI:1497260301
Name:YEPEZ, DANIEL ANDREW
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ANDREW
Last Name:YEPEZ
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 1:1600 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48216-1936
Mailing Address - Country:US
Mailing Address - Phone:313-515-8227
Mailing Address - Fax:
Practice Address - Street 1:1600 PORTER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-1936
Practice Address - Country:US
Practice Address - Phone:313-515-8227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIY120135067260Medicaid