Provider Demographics
NPI:1760475131
Name:LAW, DAVID WARREN (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WARREN
Last Name:LAW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:19117 ALLEN RD STE A
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1066
Practice Address - Country:US
Practice Address - Phone:734-676-4040
Practice Address - Fax:734-676-9897
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010O7204208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4032750OtherAETNA
MIP00717898OtherRAILROAD MEDICARE
MI137629811Medicaid
E25707Medicare UPIN
MI0E06273Medicare PIN