Provider Demographics
NPI:1518023480
Name:DETORRES, FREDERICK MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:MICHAEL
Last Name:DETORRES
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 1:6215 HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-9739
Mailing Address - Country:US
Mailing Address - Phone:231-799-8777
Mailing Address - Fax:231-798-7423
Practice Address - Street 1:6215 HARVEY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-9739
Practice Address - Country:US
Practice Address - Phone:231-799-8777
Practice Address - Fax:231-798-7423
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFD055364207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3478831Medicaid
MIFD055634OtherSTATE LICENSE
MI0618234OtherBCBS
MIF78386Medicare UPIN
MI3478831Medicaid