Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 4301064835 | MI |
NPI | 1003810839 |
---|---|
Provider Name | Braswell Drue Deen |
First Address | Southfield, MI 48075-4826 |
Second Address | Southfield, MI 48075-4825 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2005 |
Last Update Date | 24/02/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
339549910 | (05) | MI |
G57312 | (02) | MI |