Provider Demographics
NPI:1750393690
Name:HEAD, JOHN WILLIAM JR (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:HEAD
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:19450 ARGYLE CRES
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-1402
Mailing Address - Country:US
Mailing Address - Phone:313-733-7641
Mailing Address - Fax:
Practice Address - Street 1:2925 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4825
Practice Address - Country:US
Practice Address - Phone:313-396-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010115602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI595505Medicare UPIN