Provider Demographics
NPI:1548231004
Name:MCILDUFF, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:MCILDUFF
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 1:5020 W BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2919
Mailing Address - Country:US
Mailing Address - Phone:810-732-1620
Mailing Address - Fax:810-732-8559
Practice Address - Street 1:5020 W BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2919
Practice Address - Country:US
Practice Address - Phone:810-732-1620
Practice Address - Fax:810-732-8559
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJM0454952086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI105269OtherCARE CHOICE HMO
MI204105OtherMCLAREN HEALTH PLAN/ADVAN
MIB43079OtherHEALTH ALLIANCE PLAN
MIC3731OtherM-CARE
MI105269OtherPREFERRED CHOICE PPO
MI382237803109OtherCOMMUNITY CHOICE
MI0108141OtherHEALTHPLUS OF MICHIGAN
MI0202508141OtherBC/BS OF MICHIGAN
MI113646OtherGREAT LAKE HEALTH PLAN
MI1430955Medicaid
MI4294624OtherAETNA
MI0108141OtherHEALTHPLUS OF MICHIGAN
MIB56060003Medicare ID - Type Unspecified