Provider Demographics
NPI:1720030968
Name:OPOCHINSKY, FEDOR
Entity Type:Individual
Prefix:
First Name:FEDOR
Middle Name:
Last Name:OPOCHINSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:FEDOR
Other - Middle Name:
Other - Last Name:OPOCHINSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7987
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-7987
Mailing Address - Country:US
Mailing Address - Phone:586-466-9939
Mailing Address - Fax:586-466-9956
Practice Address - Street 1:215 NORTH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1716
Practice Address - Country:US
Practice Address - Phone:586-466-9939
Practice Address - Fax:586-466-9956
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010631692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI03484552-10Medicaid
2605018311OtherBCBSM
MIFO063169OtherLICENSE
MI03484552-10Medicaid