Healthcare Provider Details

I. General information

NPI: 1972108231
Provider Name (Legal Business Name): MARY ELIZABETH YALDOO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18591 W 10 MILE RD
SOUTHFIELD MI
48075-2619
US

IV. Provider business mailing address

18000 W 9 MILE RD STE 200
SOUTHFIELD MI
48075-4020
US

V. Phone/Fax

Practice location:
  • Phone: 248-935-0102
  • Fax:
Mailing address:
  • Phone: 248-336-4000
  • Fax: 248-336-9137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010296
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: