Healthcare Provider Details

I. General information

NPI: 1336373828
Provider Name (Legal Business Name): JOHN MATTHEW FELDER III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2009
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 W 13 MILE RD STE N120
ROYAL OAK MI
48073-6710
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-1550
  • Fax:
Mailing address:
  • Phone: 947-522-1848
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2015021525
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number2015021525
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2015021525
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301509615
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: