Healthcare Provider Details

I. General information

NPI: 1861060246
Provider Name (Legal Business Name): MICHAEL JOHN MASTROGIOVANNI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date: 04/28/2023
Reactivation Date: 05/11/2023

III. Provider practice location address

30795 23 MILE RD STE 207
CHESTERFIELD MI
48047-5721
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 586-421-1600
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5315266700
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351050799
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: