Basic Information
| Provider Information | |||||||||
| NPI: | 1659991271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | ELISABETH | ||||||||
| MiddleName: | LEDERMAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3626 W HURON RIVER DR | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481039489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343307945 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3990 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137457233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2020 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.