Basic Information
| Provider Information | |||||||||
| NPI: | 1164422283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTEMPA | ||||||||
| FirstName: | LESTER | ||||||||
| MiddleName: | EDWARD | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22255 GREENFIELD RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480753729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487460342 | ||||||||
| FaxNumber: | 2487460308 | ||||||||
| Practice Location | |||||||||
| Address1: | 22255 GREENFIELD RD | ||||||||
| Address2: | 132 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480753710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493301 | ||||||||
| FaxNumber: | 2488495378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 5101009556 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 434835911 | 05 | MI | MEDICAID |