Basic Information
| Provider Information | |||||||||
| NPI: | 1124471933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANDOLA | ||||||||
| FirstName: | MONICA | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18272 W 12 MILE RD | ||||||||
| Address2: | APT 204 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480762669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137422855 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 N LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH LYON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481782048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484371744 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2016 | ||||||||
| LastUpdateDate: | 07/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4301110447 | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.