Healthcare Provider Details

I. General information

NPI: 1962779124
Provider Name (Legal Business Name): CLARA TERESA VANSCYOC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2011
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22301 FOSTER WINTER DR 2ND FLOOR
SOUTHFIELD MI
48075-3707
US

IV. Provider business mailing address

22301 FOSTER WINTER DR 2ND FLOOR
SOUTHFIELD MI
48075-3707
US

V. Phone/Fax

Practice location:
  • Phone: 248-552-0620
  • Fax: 248-557-3506
Mailing address:
  • Phone: 248-552-0620
  • Fax: 248-557-3506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301034457
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: