Healthcare Provider Details

I. General information

NPI: 1700415874
Provider Name (Legal Business Name): BRANDON DAVID AHLGREN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST # 4H
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST # 4H
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 248-860-1568
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number4351051545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: