Healthcare Provider Details

I. General information

NPI: 1639557085
Provider Name (Legal Business Name): LAUREN MARIE AZEVEDO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 05/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W GRAND RIVER AVE STE 2
OKEMOS MI
48864
US

IV. Provider business mailing address

1600 W GRAND RIVER AVE STE 2
OKEMOS MI
48864-2394
US

V. Phone/Fax

Practice location:
  • Phone: 517-349-6560
  • Fax: 517-679-8232
Mailing address:
  • Phone: 517-349-6560
  • Fax: 517-679-8232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101021705
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: