Healthcare Provider Details

I. General information

NPI: 1134133762
Provider Name (Legal Business Name): ANDREA AMALFITANO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W GRAND RIVER STE 2
OKEMOS MI
48864
US

IV. Provider business mailing address

804 SERVICE RD # A201
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-349-6560
  • Fax: 517-349-5796
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number5101011076
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: