Provider Demographics
NPI:1851473094
Name:AFFATATO, ANTHONY JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOHN
Last Name:AFFATATO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15855 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3504
Mailing Address - Country:US
Mailing Address - Phone:586-263-2977
Mailing Address - Fax:
Practice Address - Street 1:15855 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-263-2977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010476207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2660637Medicaid
MI2660637Medicaid