Provider Demographics
NPI:1841234622
Name:BARACEROS, FIDELINA NITURA (MD)
Entity Type:Individual
Prefix:DR
First Name:FIDELINA
Middle Name:NITURA
Last Name:BARACEROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43750 WOODWARD AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5063
Mailing Address - Country:US
Mailing Address - Phone:248-334-6000
Mailing Address - Fax:248-334-8740
Practice Address - Street 1:43750 WOODWARD AVE
Practice Address - Street 2:STE 104
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5063
Practice Address - Country:US
Practice Address - Phone:248-334-6000
Practice Address - Fax:248-334-8740
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFB035468208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIFB035468OtherSTATE LIC NUMBER
MI101152OtherMERCY HEALTH PLAN ID #
MI3506341231OtherBCBS PROV ID #
MI195380310Medicaid
MI3506341231OtherBCBS PROV ID #