Healthcare Provider Details

I. General information

NPI: 1306848619
Provider Name (Legal Business Name): SYLVIA G MUSTONEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10809 MACK AVE
DETROIT MI
48214-2119
US

IV. Provider business mailing address

804 SERVICE RD #A201
EAST LANSING MI
48824
US

V. Phone/Fax

Practice location:
  • Phone: 313-824-1000
  • Fax: 313-824-9000
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101007658
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003956A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: