Healthcare Provider Details

I. General information

NPI: 1942357751
Provider Name (Legal Business Name): VAN C. MOMON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HENRY FORD HEALTH SYSTEM 5500 AUTO CLUB DRIVE, SUITE 160
DEARBORN MI
48126
US

IV. Provider business mailing address

HENRY FORD HEALTH SYSTEM 5500 AUTO CLUB DRIVE, SUITE 160
DEARBORN MI
48126
US

V. Phone/Fax

Practice location:
  • Phone: 313-425-4700
  • Fax:
Mailing address:
  • Phone: 313-425-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301047888
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: