Provider Demographics
NPI:1851318752
Name:CHODOROFF, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:CHODOROFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30100 TELEGRAPH RD
Mailing Address - Street 2:SUITE 177
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4514
Mailing Address - Country:US
Mailing Address - Phone:248-647-1470
Mailing Address - Fax:248-647-1472
Practice Address - Street 1:30100 TELEGRAPH RD
Practice Address - Street 2:SUITE 177
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4560
Practice Address - Country:US
Practice Address - Phone:248-647-1470
Practice Address - Fax:248-647-1472
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGC046805208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI49558OtherHAP THRU PROVIDENCE
MI0633719OtherBLUE CARE NETWORK
MI101420OtherPREFERRED CHOICE
MI4052753OtherAETNA
MI1106337OtherBLUE CROSS BLUE SHIELD
MI250F334790OtherBLUE CROSS BLUE SHIELD
MI101420OtherCARE CHOICE
MIC3352OtherMCARE
MIC3352OtherMCARE
MI0633719Medicare ID - Type Unspecified
MI49558OtherHAP THRU PROVIDENCE