Healthcare Provider Details

I. General information

NPI: 1740625524
Provider Name (Legal Business Name): LYDIA JOY RAYES D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18303 E 10 MILE RD SUITE 500
ROSEVILLE MI
48066-4988
US

IV. Provider business mailing address

18303 E 10 MILE RD SUITE 500
ROSEVILLE MI
48066-4988
US

V. Phone/Fax

Practice location:
  • Phone: 586-498-5160
  • Fax: 586-498-5199
Mailing address:
  • Phone: 586-498-5160
  • Fax: 586-498-5199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101020473
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: