Provider Demographics
NPI:1669028569
Name:HUGHES, DEANDRE LAVELLE
Entity Type:Individual
Prefix:
First Name:DEANDRE
Middle Name:LAVELLE
Last Name:HUGHES
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 1:706 PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-4194
Mailing Address - Country:US
Mailing Address - Phone:989-400-2583
Mailing Address - Fax:989-956-5914
Practice Address - Street 1:706 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-4194
Practice Address - Country:US
Practice Address - Phone:989-400-2583
Practice Address - Fax:989-956-5914
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIH220139488070172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty