Basic Information
| Provider Information | |||||||||
| NPI: | 1356088140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOBSON | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | ANTONIO | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 BREWERY PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134464444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1333 BREWERY PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134464444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2022 | ||||||||
| LastUpdateDate: | 05/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | 3662751919 | MI | Y | Other Service Providers | Community Health Worker |
No ID Information.