Provider Demographics
NPI:1457355737
Name:DERDERIAN, GREGORY PAUL (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:DERDERIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 N OLD WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-5375
Mailing Address - Country:US
Mailing Address - Phone:248-594-3091
Mailing Address - Fax:248-594-3068
Practice Address - Street 1:538 N OLD WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-5375
Practice Address - Country:US
Practice Address - Phone:248-594-3091
Practice Address - Fax:248-594-3068
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010071822086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4406461Medicaid
MIE25897Medicare UPIN
MI4406461Medicaid