Healthcare Provider Details

I. General information

NPI: 1275916231
Provider Name (Legal Business Name): CHRISTINA DOULAVERAKIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR SUITE 500
SOUTHFIELD MI
48075-4825
US

IV. Provider business mailing address

3871 HOWARD AVE
WINDSOR ONT
N9G 1N6
CA

V. Phone/Fax

Practice location:
  • Phone: 248-849-3441
  • Fax:
Mailing address:
  • Phone: 226-246-4627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301107303
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: