Basic Information
| Provider Information | |||||||||
| NPI: | 1902029713 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | E J DAROS DO PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FAMILY DOCS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8275 HOLLY RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484392442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106030990 | ||||||||
| FaxNumber: | 8106031678 | ||||||||
| Practice Location | |||||||||
| Address1: | 8275 HOLLY RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484392442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106030990 | ||||||||
| FaxNumber: | 8106031678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAROS | ||||||||
| AuthorizedOfficialFirstName: | EVTISHIOS | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8106030990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ED007048 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1003800350 | 01 | MI | NPI INDIVIDUAL | OTHER | 4614320 | 05 | MI | MEDICAID | ED007048 | 01 | MI | STATE LICENSE NUMBER | OTHER | 080B511230 | 01 | MI | BCBSM | OTHER | DM076048 | 01 | MI | STATE LICENSE NUMBER | OTHER | $$$$$$$$$ | 01 | MI | SSN | OTHER | AD013144 | 01 | MI | STATE LICENSE NUMBER | OTHER | 1316944333 | 01 | MI | NPI INDIVIDUAL | OTHER | 1841284437 | 01 | MI | NPI INDIVIDUAL | OTHER | $$$$$$$$$ | 01 | MI | SSN | OTHER | 2095522 | 05 | MI | MEDICAID | 4613396 | 05 | MI | MEDICAID | $$$$$$$$$ | 01 | MI | SSN | OTHER |