Healthcare Provider Details

I. General information

NPI: 1295828358
Provider Name (Legal Business Name): ANDREW I. DZUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 E 12 MILE RD SUITE 111
SAINT CLAIR SHORES MI
48081-1116
US

IV. Provider business mailing address

21000 E 12 MILE RD STE 111
ST CLAIR SHORES MI
48081
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-7610
  • Fax:
Mailing address:
  • Phone: 586-779-7610
  • Fax: 586-445-2523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberAD044645
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: