Healthcare Provider Details

I. General information

NPI: 1770602500
Provider Name (Legal Business Name): CEDERICK DEON CISTRUNK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 JOHN R ST
DETROIT MI
48201-2018
US

IV. Provider business mailing address

3990 JOHN R DEPT OF CARDIO THORACIC SURGERY
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-8040
  • Fax:
Mailing address:
  • Phone: 313-745-7045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601004965
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: