Healthcare Provider Details

I. General information

NPI: 1174637995
Provider Name (Legal Business Name): MARK E LEVENTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12337 E MICHIGAN AVE
GRASS LAKE MI
49240-0246
US

IV. Provider business mailing address

PO BOX 246
GRASS LAKE MI
49240-0246
US

V. Phone/Fax

Practice location:
  • Phone: 517-522-8403
  • Fax: 517-522-4275
Mailing address:
  • Phone: 517-522-8403
  • Fax: 517-522-4275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberML041377
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: