Provider Demographics
NPI:1942390976
Name:PEVZNER, MARTIN MITCHELL (MD,)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:MITCHELL
Last Name:PEVZNER
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:DR
Other - First Name:MARTIN
Other - Middle Name:M
Other - Last Name:PEVZNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:32270 TELEGRAPH RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2456
Mailing Address - Country:US
Mailing Address - Phone:248-646-1965
Mailing Address - Fax:248-594-7158
Practice Address - Street 1:32270 TELEGRAPH RD
Practice Address - Street 2:SUITE 120
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2456
Practice Address - Country:US
Practice Address - Phone:248-646-1965
Practice Address - Fax:248-594-7158
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029995207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI15748575Medicaid
MI382515402OtherTAX ID NUMBER
MIB44142Medicare UPIN
MI15748575Medicaid