Provider Demographics
NPI:1245282771
Name:DEODORICO, IRIS (MD)
Entity type:Individual
Prefix:DR
First Name:IRIS
Middle Name:
Last Name:DEODORICO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 GULL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1650
Mailing Address - Country:US
Mailing Address - Phone:269-388-6350
Mailing Address - Fax:269-388-4738
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1650
Practice Address - Country:US
Practice Address - Phone:269-388-6350
Practice Address - Fax:269-388-4738
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010625562085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4843037Medicaid
MI4635885Medicaid
MI4635885Medicaid
G34134Medicare UPIN
MIP26160002Medicare ID - Type Unspecified