Provider Demographics
NPI:1508660309
Name:ROE, AVERY (DO)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:ROE
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3911 N GOLDENROD ST
Mailing Address - Street 2:
Mailing Address - City:MAIZE
Mailing Address - State:KS
Mailing Address - Zip Code:67101-3741
Mailing Address - Country:US
Mailing Address - Phone:480-298-0233
Mailing Address - Fax:
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-569-7745
Practice Address - Fax:248-569-4539
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151017239APP25207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery