Healthcare Provider Details

I. General information

NPI: 1679968150
Provider Name (Legal Business Name): MICHAEL DEWALL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E HURON RIVER DR
YPSILANTI MI
48197-1051
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR LBBY J2000
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-3161
  • Fax: 734-712-2244
Mailing address:
  • Phone: 734-747-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5101025453
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number5101025453
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number5101025453
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: