Provider Demographics
NPI:1356359202
Name:COWLES, CLARISSA C (MD)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:C
Last Name:COWLES
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 1:30625 WOODGATE
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:248-433-1247
Mailing Address - Fax:
Practice Address - Street 1:5130 COOLIDGE HIGHWAY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-288-9500
Practice Address - Fax:248-288-0044
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM143041361207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1604702141OtherBCBS IND
MI1356359202Medicaid
MI700H231390OtherBCBS GROUP NUMBER
MI700H231390OtherBCBS GROUP NUMBER
MIMI4614002Medicare PIN