Provider Demographics
NPI:1750312641
Name:DIDLUCH, MAREK T (MD)
Entity Type:Individual
Prefix:DR
First Name:MAREK
Middle Name:T
Last Name:DIDLUCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 S. LINDEN RD.
Mailing Address - Street 2:STE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532
Mailing Address - Country:US
Mailing Address - Phone:810-720-8700
Mailing Address - Fax:810-720-3393
Practice Address - Street 1:2265 S. LINDEN RD.
Practice Address - Street 2:STE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532
Practice Address - Country:US
Practice Address - Phone:810-720-8700
Practice Address - Fax:810-720-3393
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301085501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104730839Medicaid
MI381870664OtherPPOM
MIMD085501OtherLICENSE NUMBER
MI7616564OtherAETNA
MI0731145OtherBCBSM
MI149834OtherGREAT LAKES HEALTH PLAN
MI080G376200OtherBCBSM
MI381870664OtherHEALTH CARE ALLIANCE POOL
MI381870664OtherPRIVATE HEALTH CARE SYSTE
MI381870664OtherPRIORITY HEALTHCARE
MIMD085501OtherLICENSE NUMBER
MI0G37620Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MI381870664OtherPRIVATE HEALTH CARE SYSTE
MI149834OtherGREAT LAKES HEALTH PLAN
MII21322Medicare UPIN