Healthcare Provider Details

I. General information

NPI: 1174134522
Provider Name (Legal Business Name): GEOFFREY YANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR
SOUTHFIELD MI
48075-4825
US

IV. Provider business mailing address

22250 PROVIDENCE DR
SOUTHFIELD MI
48075-4825
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-5862
  • Fax: 248-849-8117
Mailing address:
  • Phone: 248-849-5862
  • Fax: 248-849-8117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4351056761
License Number StateMI
# 2
Primary TaxonomyN
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: