Provider Demographics
NPI:1518917533
Name:URDANIVIA, ENRIQUE
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:URDANIVIA
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 1:3234 MONTMARTE CIR
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-3541
Mailing Address - Country:US
Mailing Address - Phone:248-737-8043
Mailing Address - Fax:
Practice Address - Street 1:4700 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3698
Practice Address - Country:US
Practice Address - Phone:313-581-2600
Practice Address - Fax:313-581-0228
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037751207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236661OtherMEDICARE PROVIDER NO
MI001007OtherMIDWEST HEALTH PLAN
MI123355OtherGREAT LAKES HEALTH PLAN
MI50805OtherOMNICARE HEALTH PLAN
MIB42918OtherHEALTH ALLIANCE PLAN
MI101379155Medicaid
MI4558034OtherAETNA
MI110Q262840OtherBCBSM/BCN
MIB42918Medicare UPIN
MI0Q26284023Medicare ID - Type Unspecified