Healthcare Provider Details

I. General information

NPI: 1518175116
Provider Name (Legal Business Name): JENNIFER TREPTE CAUDILL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5885 S. MAIN ST. SUITE 1
CLARKSTON MI
48346
US

IV. Provider business mailing address

5885 S. MAIN ST. SUITE 1
CLARKSTON MI
48346
US

V. Phone/Fax

Practice location:
  • Phone: 248-623-9700
  • Fax: 248-623-8996
Mailing address:
  • Phone: 248-623-9700
  • Fax: 248-623-8996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301086079
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: