Provider Demographics
NPI:1619032851
Name:DIDOCHA, DANIEL WALTER (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:WALTER
Last Name:DIDOCHA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2803 HAVERFORD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5333
Mailing Address - Country:US
Mailing Address - Phone:248-703-9486
Mailing Address - Fax:248-641-1406
Practice Address - Street 1:40 OAK HOLLOW ST
Practice Address - Street 2:SUITE 350
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7408
Practice Address - Country:US
Practice Address - Phone:248-354-0581
Practice Address - Fax:248-641-1406
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2112857110Medicaid
MI1631927011Medicare ID - Type Unspecified
MI2112857110Medicaid