Healthcare Provider Details

I. General information

NPI: 1669737961
Provider Name (Legal Business Name): LUSINE B KIRAKOSYAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25100 KELLY RD
ROSEVILLE MI
48066
US

IV. Provider business mailing address

893 LAFAYETTE CT
ROCHESTER HILLS MI
48307-2919
US

V. Phone/Fax

Practice location:
  • Phone: 586-771-7440
  • Fax: 586-771-9966
Mailing address:
  • Phone: 910-546-1771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301100589
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301100589
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: