Provider Demographics
NPI:1669583332
Name:MOUTSATSON, MICHAEL JAMES (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:MOUTSATSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2890 HEALTH PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-953-9777
Mailing Address - Fax:989-773-6267
Practice Address - Street 1:2890 HEALTH PARKWAY
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-953-9777
Practice Address - Fax:989-773-6267
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM014511207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4775590Medicaid
MI0P20460Medicare PIN
MII35838Medicare UPIN