Healthcare Provider Details

I. General information

NPI: 1255542502
Provider Name (Legal Business Name): DAVID PERRY DEETER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MC 482-C10-092 300 RENAISSANCE DR
DETROIT MI
48265-3000
US

IV. Provider business mailing address

304 HAMPTON WOODS LN
LAKE ORION MI
48360-1220
US

V. Phone/Fax

Practice location:
  • Phone: 313-665-1620
  • Fax:
Mailing address:
  • Phone: 284-814-0611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number4301082903
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: