Healthcare Provider Details

I. General information

NPI: 1669267456
Provider Name (Legal Business Name): MAXWELL GREY WHEATON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD
DETROIT MI
48236-2148
US

IV. Provider business mailing address

38967 PARKWAY CIR
HARRISON TOWNSHIP MI
48045-6812
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-8797
  • Fax: 313-343-7620
Mailing address:
  • Phone: 586-484-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: