Provider Demographics
NPI:1689100273
Name:FELICIDARIO, IRYL
Entity type:Individual
Prefix:
First Name:IRYL
Middle Name:
Last Name:FELICIDARIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 HARNED DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-1046
Mailing Address - Country:US
Mailing Address - Phone:248-689-2056
Mailing Address - Fax:248-689-4283
Practice Address - Street 1:2033 HARNED DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1046
Practice Address - Country:US
Practice Address - Phone:248-689-2056
Practice Address - Fax:248-689-4283
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS630066532171W00000X
MIAS630079486171W00000X
MIAS500363588171W00000X
MIAS500012029171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor