Healthcare Provider Details

I. General information

NPI: 1063862415
Provider Name (Legal Business Name): FRITZ DANIEL BRINK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 08/31/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 PASADENA AVE S STE 3M
SOUTH PASADENA FL
33707-4563
US

IV. Provider business mailing address

1501 PASADENA AVE S
SOUTH PASADENA FL
33707-3717
US

V. Phone/Fax

Practice location:
  • Phone: 586-576-4140
  • Fax: 586-576-4146
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101022720
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: