Healthcare Provider Details

I. General information

NPI: 1831142306
Provider Name (Legal Business Name): LITON MECANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10047 CROSSROAD CT SE
CALEDONIA MI
49316-7316
US

IV. Provider business mailing address

245 STATE ST SE
GRAND RAPIDS MI
49503-4328
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8450
  • Fax: 616-458-3526
Mailing address:
  • Phone: 616-685-1808
  • Fax: 616-685-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301062209
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: