Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 5101009690 | MI |
N | 208G00000X | Cardiothoracic Vascular Surgeon | DF009690 | MI |
NPI | 1043315260 |
---|---|
Provider Name | David J Fertel |
First Address | Commerce Twp, MI 48382-4330 |
Second Address | Westland, MI 48185-7128 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2006 |
Last Update Date | 13/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E23545 | (02) | MI |