Provider Demographics
NPI:1952521874
Name:IVORY, MICHAEL ERIC (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ERIC
Last Name:IVORY
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 1:4070 N CHIPMAN ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-9444
Mailing Address - Country:US
Mailing Address - Phone:989-723-5236
Mailing Address - Fax:
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-726-8740
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007170208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30010400Medicaid
MI4709700Medicaid
MI4709700Medicaid