Doctor Name: | DR. DAVID A DETRISAC |
NPI Number: | 1730185539 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MD |
License Number: | 4301044478 |
Business Practice Address: | 3394 E Jolly Rd Ste A Lansing, MI - 489108595 |
Business Phone Number: | 5173943200 |
Business Fax Number: | 5173944250 |
Mailing Address: | 3394 E Jolly Rd, Ste A LANSING |
State: | MI |
Postal Code: | 489108595 |
Phone Number: | 5173943200 |
Fax Number: | 5173944250 |
NPI Enumeration Date: | 06/27/2005 |
NPI Last Update Date: | 11/19/2009 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 174400000X |
License Number: | 4301044478 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MI |
Taxonomy Type: | Other Service Providers |
Taxonomy Classification: | Specialist |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |