Provider Demographics
NPI:1063528958
Name:MIDDELDORF, JEFFREY EDWIN (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EDWIN
Last Name:MIDDELDORF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:888 WEST BIG BEAVER ROAD
Mailing Address - Street 2:SUITE 480
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4764
Mailing Address - Country:US
Mailing Address - Phone:248-797-8324
Mailing Address - Fax:248-816-5173
Practice Address - Street 1:5700 E 11 MILE ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089
Practice Address - Country:US
Practice Address - Phone:586-558-4482
Practice Address - Fax:586-558-8923
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI2301003007111N00000X
MI5101012371208100000X
NY2238841208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3742088Medicaid
2555002114BX33OtherBC/BS
2555002114BX33OtherBC/BS
MI3742088Medicaid