Provider Demographics
NPI:1043315260
Name:FERTEL, DAVID J (D O)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:FERTEL
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 LOCH BEND DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-4330
Mailing Address - Country:US
Mailing Address - Phone:248-932-2607
Mailing Address - Fax:248-932-2863
Practice Address - Street 1:6149 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-7128
Practice Address - Country:US
Practice Address - Phone:734-728-2130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDF009690208G00000X
MI5101009690208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE23545Medicare UPIN
MI0N84530Medicare ID - Type Unspecified