Provider Demographics
NPI:1538501150
Name:ALCODRAY, ABDUL
Entity Type:Individual
Prefix:
First Name:ABDUL
Middle Name:
Last Name:ALCODRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:ALCODRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19023 ASPEN DR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4811
Mailing Address - Country:US
Mailing Address - Phone:248-536-2250
Mailing Address - Fax:248-536-2250
Practice Address - Street 1:19023 ASPEN DR
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-4811
Practice Address - Country:US
Practice Address - Phone:248-536-2250
Practice Address - Fax:248-536-2250
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIA423029031812172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver