Provider Demographics
NPI:1336212216
Name:LOVE, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:LOVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 KINGS CARRIAGE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8787
Mailing Address - Country:US
Mailing Address - Phone:810-694-2962
Mailing Address - Fax:810-733-5991
Practice Address - Street 1:1403 KINGS CARRIAGE RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8787
Practice Address - Country:US
Practice Address - Phone:810-694-2962
Practice Address - Fax:810-733-5991
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2019-02-13
Deactivation Date:2015-11-20
Deactivation Code:
Reactivation Date:2019-01-11
Provider Licenses
StateLicense IDTaxonomies
MI4301036549207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB44174Medicare UPIN
02592632072Medicare ID - Type Unspecified