Basic Information
| Provider Information | |||||||||
| NPI: | 1184760670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YANGA | ||||||||
| FirstName: | ISMAEL | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12851 GRAND RIVER RD | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481168506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102252506 | ||||||||
| FaxNumber: | 8102205509 | ||||||||
| Practice Location | |||||||||
| Address1: | 12851 GRAND RIVER RD | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481168506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102252506 | ||||||||
| FaxNumber: | 8102205509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301084033 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 4301084033 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5214028 | 05 | MI | MEDICAID |