Healthcare Provider Details

I. General information

NPI: 1275949182
Provider Name (Legal Business Name): ALEXANDER DER-TEN YANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date: 02/12/2015
Reactivation Date: 03/31/2015

III. Provider practice location address

1101 W. UNIVERSITY DRIVE, 2-SOUTH WAYNE STATE FAMILY MEDICINE PROGRAM
ROCHESTER MI
48307
US

IV. Provider business mailing address

1101 W. UNIVERSITY DRIVE, 2-SOUTH WAYNE STATE FAMILY MEDICINE PROGRAM
ROCHESTER MI
48307
US

V. Phone/Fax

Practice location:
  • Phone: 248-601-4900
  • Fax:
Mailing address:
  • Phone: 248-601-4900
  • 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: