Provider Demographics
NPI:1891282935
Name:DEVER, MICHAEL ANDREW
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:DEVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2328 S LAKELINE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1462
Mailing Address - Country:US
Mailing Address - Phone:801-502-8392
Mailing Address - Fax:
Practice Address - Street 1:29000 LITTLE MACK AVE STE B
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3018
Practice Address - Country:US
Practice Address - Phone:586-774-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-14
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301508579208600000X
OH57.245966208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery