Healthcare Provider Details

I. General information

NPI: 1558538132
Provider Name (Legal Business Name): DAVID O WASHINGTON MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19251 BRETTON DR
DETROIT MI
48223-1363
US

IV. Provider business mailing address

19251 BRETTON DR
DETROIT MI
48223-1363
US

V. Phone/Fax

Practice location:
  • Phone: 313-452-0384
  • Fax:
Mailing address:
  • Phone: 313-452-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number4301062062
License Number StateMI

VIII. Authorized Official

Name: DAVID O WASHINGTON
Title or Position: OWNER
Credential: MD
Phone: 313-452-0384