Healthcare Provider Details

I. General information

NPI: 1457357055
Provider Name (Legal Business Name): MIRAFLOR REYES-GANZON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N JACKSON ST
JACKSON MI
49201-1266
US

IV. Provider business mailing address

505 N JACKSON ST
JACKSON MI
49201-1266
US

V. Phone/Fax

Practice location:
  • Phone: 517-748-5500
  • Fax: 517-780-9286
Mailing address:
  • Phone: 517-748-5500
  • Fax: 517-780-9286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301068653
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: