Healthcare Provider Details

I. General information

NPI: 1508004920
Provider Name (Legal Business Name): BRIAN G. LODER DPM PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43391 COMMONS DR
CLINTON TWP MI
48038-1109
US

IV. Provider business mailing address

15760 19 MILE RD STE E
CLINTON TWP MI
48038-6319
US

V. Phone/Fax

Practice location:
  • Phone: 586-329-3895
  • Fax: 586-329-3916
Mailing address:
  • Phone: 586-329-3895
  • Fax: 586-329-3916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901001662
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMI

VIII. Authorized Official

Name: BRIAN GEORGE LODER
Title or Position: OWNER
Credential: DPM
Phone: 586-329-3895