Provider Demographics
NPI:1295719896
Name:LOBO, ATHANASIUS Z (MD)
Entity type:Individual
Prefix:DR
First Name:ATHANASIUS
Middle Name:Z
Last Name:LOBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4825
Mailing Address - Country:US
Mailing Address - Phone:248-569-0288
Mailing Address - Fax:248-569-0520
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-569-0288
Practice Address - Fax:248-569-0520
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430103354207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110175608OtherRR MEDICARE
MI129571896Medicaid
MI0637609OtherBCBS INDIVIDUAL
MI700F314390OtherBLUE SHIELD
MI129571896Medicaid
MI0M55740Medicare ID - Type Unspecified
MI0M96210107Medicare PIN