Healthcare Provider Details

I. General information

NPI: 1710397690
Provider Name (Legal Business Name): OLGA GENNADYEVNA DEWALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: OLGA GENNADYEVNA KUNSHINA M.D.

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

1859 COBBLE CT
BRIGHTON MI
48114-7658
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 248-252-5457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301105687
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: