Healthcare Provider Details

I. General information

NPI: 1275947145
Provider Name (Legal Business Name): ANGELICO RAZON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR 3116 TAUBMAN CENTER, SPC 5368
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

1500 E MEDICAL CENTER DR 3116 TAUBMAN CENTER, SPC 5368
ANN ARBOR MI
48109-5000
US

V. Phone/Fax

Practice location:
  • Phone: 734-647-6670
  • Fax: 734-647-6661
Mailing address:
  • Phone: 734-647-6670
  • Fax: 734-647-6661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301105809
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: