Provider Demographics
NPI:1669470035
Name:BOYLE, JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BOYLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 HAGGERTY RD
Mailing Address - Street 2:SUITE # 2110
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2184
Mailing Address - Country:US
Mailing Address - Phone:248-926-1411
Mailing Address - Fax:248-926-5338
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:SUITE # 2110
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2184
Practice Address - Country:US
Practice Address - Phone:248-926-1411
Practice Address - Fax:248-926-5338
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJB014559208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI45392270Medicaid
MI7755470OtherAETNA
MI350F375630OtherBCBSM
MI3008001OtherCIGNA
MI383379540OtherTAX ID
MI350F375630OtherBCBSM
MI45392270Medicaid