Basic Information
Provider Information | |||||||||
NPI: | 1538147558 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YANGOUYIAN | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 38935 ANN ARBOR RD | ||||||||
Address2: | CREDENTIALING / PAYER CONTRACTING | ||||||||
City: | LIVONIA | ||||||||
State: | MI | ||||||||
PostalCode: | 481503397 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7346320175 | ||||||||
FaxNumber: | 8662506385 | ||||||||
Practice Location | |||||||||
Address1: | 18101 OAKWOOD BLVD | ||||||||
Address2: |   | ||||||||
City: | DEARBORN | ||||||||
State: | MI | ||||||||
PostalCode: | 481244089 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3135937000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2006 | ||||||||
LastUpdateDate: | 11/14/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 5101013499 | MI | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 5101013499 | MI | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 0102202212 | VA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 11292475 | 01 |   | CAQH | OTHER |