Provider Demographics
NPI:1508816539
Name:VIVIANO, DAVID MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MATTHEW
Last Name:VIVIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N CRANBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-2608
Mailing Address - Country:US
Mailing Address - Phone:248-821-6161
Mailing Address - Fax:
Practice Address - Street 1:1380 COOLIDGE HWY STE 110
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-7067
Practice Address - Country:US
Practice Address - Phone:248-288-2200
Practice Address - Fax:248-288-2278
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060296207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200H261280OtherBCBSM/BCN
MI236661OtherMEDICARE PROVIDER NO
MI104087038Medicaid
MI006476OtherMIDWEST HEALTH PLANS
MI116527OtherGREAT LAKES HEALTH PLAN
MIG97179OtherHEALTH ALLIANCE PLANS
MI50807OtherOMNICARE HEALTH PLANS
MI7979762OtherAETNA