Healthcare Provider Details

I. General information

NPI: 1396827374
Provider Name (Legal Business Name): YIJUN PANG M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E HURON RIVER DR
YPSILANTI MI
48197
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR LBBY J2000
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-3161
  • Fax: 734-712-2244
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301086133
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number35.091830
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number4301086133
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: