Healthcare Provider Details

I. General information

NPI: 1861708257
Provider Name (Legal Business Name): JEFFREY A. LONDON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 W BIG BEAVER RD SUITE 520
TROY MI
48084-3407
US

IV. Provider business mailing address

2075 W BIG BEAVER RD SUITE 520
TROY MI
48084-3407
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-6659
  • Fax: 248-642-8645
Mailing address:
  • Phone: 248-646-6659
  • Fax: 248-642-8645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number4301040691
License Number StateMI

VIII. Authorized Official

Name: JEFFREY A, LONDON
Title or Position: PRESIDENT
Credential: MD
Phone: 248-646-6659