Healthcare Provider Details

I. General information

NPI: 1003964719
Provider Name (Legal Business Name): KOICHI MAEDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD 2799 WEST GRAND BOULEVARD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

2799 W GRAND BLVD 2799 WEST GRAND BOULEVARD
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2436
  • Fax:
Mailing address:
  • Phone: 313-916-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number034888
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number034888
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: