Basic Information
| Provider Information | |||||||||
| NPI: | 1083816136 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | HARRIS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD | ||||||||
| Address2: | SUITE 3D | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221861 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488989060 | ||||||||
| FaxNumber: | 2488989054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4301096457 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207ZB0001X | ME111481 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004370800 | 05 | FL | MEDICAID |