Healthcare Provider Details

I. General information

NPI: 1649489808
Provider Name (Legal Business Name): ANDREW JOSEPH DETTORE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23050 WEST RD STE. 110
BROWNSTOWN TWP MI
48183-1472
US

IV. Provider business mailing address

23125 WAGONWHEEL DR
BROWNSTOWN TWP MI
48183-1160
US

V. Phone/Fax

Practice location:
  • Phone: 734-671-9800
  • Fax: 734-671-7690
Mailing address:
  • Phone: 248-981-5769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101014925
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: