Healthcare Provider Details

I. General information

NPI: 1497572465
Provider Name (Legal Business Name): JAMES EARL WASHINGTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22756 TEPPERT AVE
EASTPOINTE MI
48021-1928
US

IV. Provider business mailing address

22756 TEPPERT AVE
EASTPOINTE MI
48021-1928
US

V. Phone/Fax

Practice location:
  • Phone: 586-935-7616
  • Fax:
Mailing address:
  • Phone: 586-935-7616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberW252367162111
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: