Provider Demographics
NPI:1952504987
Name:MARIA LIVIERATOS MD PLLC
Entity Type:Organization
Organization Name:MARIA LIVIERATOS MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVIERATOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:248-620-1275
Mailing Address - Street 1:5799 S. MAIN ST. #1472
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48347-1472
Mailing Address - Country:US
Mailing Address - Phone:248-620-1275
Mailing Address - Fax:
Practice Address - Street 1:5799 S MAIN ST
Practice Address - Street 2:#1472
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48347-9907
Practice Address - Country:US
Practice Address - Phone:248-620-1275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301064240OtherBOARD OF MEDICINE PHYSICI
MIH09333Medicare UPIN
MION56570Medicare PIN