Healthcare Provider Details

I. General information

NPI: 1033104773
Provider Name (Legal Business Name): DANIEL SETH ZUCKERBROD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14400 WEST MCNICHOLS
DETROIT MI
48235-3916
US

IV. Provider business mailing address

43996 WOODWARD AVE SUITE 101
BLOOMFIELD HILLS MI
48302-5027
US

V. Phone/Fax

Practice location:
  • Phone: 313-341-3450
  • Fax: 313-341-2135
Mailing address:
  • Phone: 248-332-4544
  • Fax: 248-332-2716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301077700
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: