Healthcare Provider Details

I. General information

NPI: 1053571885
Provider Name (Legal Business Name): NATALIE RENEE KONTOS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS RD PROFESSIONAL BUILDING 2, SUITE 70
DETROIT MI
48236-2169
US

IV. Provider business mailing address

22201 MOROSS RD PROFESSIONAL BUILDING 2, SUITE 70
DETROIT MI
48236-2169
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-4279
  • Fax: 313-343-7937
Mailing address:
  • Phone: 313-343-4279
  • Fax: 313-343-7937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101017823
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: