Healthcare Provider Details

I. General information

NPI: 1194352815
Provider Name (Legal Business Name): JOHN EFTHYVOULIDIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15855 19 MILE RD
CLINTON TOWNSHIP MI
48038-3504
US

IV. Provider business mailing address

15855 19 MILE RD
CLINTON TOWNSHIP MI
48038-3504
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5151014423
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: