Provider Demographics
NPI:1487618575
Name:DEPOLO, ALBERT A JR (DO)
Entity type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:A
Last Name:DEPOLO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:809 E. MICHIGAN AVE.
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738
Mailing Address - Country:US
Mailing Address - Phone:989-348-6610
Mailing Address - Fax:989-348-2723
Practice Address - Street 1:809 E. MICHIGAN AVE.
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738
Practice Address - Country:US
Practice Address - Phone:989-348-6610
Practice Address - Fax:989-348-2723
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101007832208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI111768805Medicaid
MI111768805Medicaid