Healthcare Provider Details

I. General information

NPI: 1376978643
Provider Name (Legal Business Name): DDPMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 W BIG BEAVER RD SUITE 1200
TROY MI
48084-4900
US

IV. Provider business mailing address

17376 W 12 MILE RD STE 200
SOUTHFIELD MI
48076-6303
US

V. Phone/Fax

Practice location:
  • Phone: 248-273-7700
  • Fax: 248-273-7701
Mailing address:
  • Phone: 914-629-1887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301103946
License Number StateMI

VIII. Authorized Official

Name: DR. DANIELLE DELUCA-PYTELL
Title or Position: CEO
Credential: M.D.
Phone: 91406291887