Healthcare Provider Details

I. General information

NPI: 1134000599
Provider Name (Legal Business Name): XIAOLAN FANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

1732 BIRMINGHAM BLVD
BIRMINGHAM MI
48009-1922
US

V. Phone/Fax

Practice location:
  • Phone: 313-542-2698
  • Fax:
Mailing address:
  • Phone: 313-542-2698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License Number2023057
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License Number2023057
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207SG0205X
TaxonomyPh.D. Medical Genetics Physician
License Number2023057
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: