Provider Demographics
NPI:1659316842
Name:DOELLE, KARL MARTIN (DO)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:MARTIN
Last Name:DOELLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:ATTENTION: BARBRA SIMMONS
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:734-677-7400
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:1000 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2920
Practice Address - Country:US
Practice Address - Phone:586-493-8098
Practice Address - Fax:586-493-8706
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010119892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4458726Medicaid
MI3155000384OtherBCBS INDIVIDUAL #
MI4423785Medicaid
MI0N78920Medicare PIN
MI4423785Medicaid
MI4458726Medicaid