Basic Information
| Provider Information | |||||||||
| NPI: | 1790774131 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUTKOWI TOOMAJIAN | ||||||||
| FirstName: | LYNETTE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SUTKOWI | ||||||||
| OtherFirstName: | LYNETTE | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13355 E 10 MILE RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480892048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867567090 | ||||||||
| FaxNumber: | 5867567091 | ||||||||
| Practice Location | |||||||||
| Address1: | 13355 E 10 MILE RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480892048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867567090 | ||||||||
| FaxNumber: | 5867567091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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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 | 207RX0202X | 5101012826 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4343595-11 | 05 | MI | MEDICAID |