Provider Demographics
NPI:1508898123
Name:MIDDLEBROOK, DEON DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DEON
Middle Name:DAVID
Last Name:MIDDLEBROOK
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 1:20176 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1346
Mailing Address - Country:US
Mailing Address - Phone:313-864-7000
Mailing Address - Fax:313-864-5769
Practice Address - Street 1:20176 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-1346
Practice Address - Country:US
Practice Address - Phone:313-864-7000
Practice Address - Fax:313-864-5423
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053010207RN0300X
MIDM053010174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102889716Medicaid
MIE02863Medicare UPIN
MI0Q24659001Medicare ID - Type Unspecified