Healthcare Provider Details

I. General information

NPI: 1730135294
Provider Name (Legal Business Name): INFECTIOUS DISEASES ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MCAULEY DR R3106
YPSILANTI MI
48197-1014
US

IV. Provider business mailing address

5333 MCAULEY DR R3106
YPSILANTI MI
48197-1014
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-8600
  • Fax:
Mailing address:
  • Phone: 734-712-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number029166
License Number StateMI

VIII. Authorized Official

Name: DR. MICHAEL OTTO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 734-712-8600