Healthcare Provider Details

I. General information

NPI: 1487618575
Provider Name (Legal Business Name): ALBERT A DEPOLO JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 E. MICHIGAN AVE.
GRAYLING MI
49738
US

IV. Provider business mailing address

809 E. MICHIGAN AVE.
GRAYLING MI
49738
US

V. Phone/Fax

Practice location:
  • Phone: 989-348-6610
  • Fax: 989-348-2723
Mailing address:
  • Phone: 989-348-6610
  • Fax: 989-348-2723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5101007832
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: