Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 5901001503 | MI |
NPI | 1417904376 |
---|---|
Provider Name | Durene M Elem-Vaughn |
First Address | Lincoln Park, MI 48146-1802 |
Second Address | Lincoln Park, MI 48146-1802 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2006 |
Last Update Date | 19/09/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2710766 | (05) | MI |
4858252150 | BLUE CROSS BLUE SHIELD (01) | MI |
U16476 | (02) | MI |