Healthcare Provider Details

I. General information

NPI: 1023842390
Provider Name (Legal Business Name): CEDRIC LAVAR MAYFIELD JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 SAGAMORE PKWY W
WEST LAFAYETTE IN
47906-1501
US

IV. Provider business mailing address

33464 HERITAGE HILLS DR
FARMINGTON HILLS MI
48331-1559
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-448-7604
Mailing address:
  • Phone: 313-258-9488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: