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General NPI Number Information
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NPI Number | 1801888904
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Entity Type | Individual
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Provider Name | MAZIN PUTRUS YONAN MD
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Gender | Male
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Dates
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Enumeration Date | 08/16/2005
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Last Update Date | 10/27/2011
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Provider Practice Location Address
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Address Line | 2221 LIVERNOIS RD 100
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City | TROY
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State | MI
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Zip | 48083-1603
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Country | US
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Telephone | 248-250-9474
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Fax | 248-250-9483
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Provider Business Mailing Address
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Address Line | 2221 LIVERNOIS RD 100
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City | TROY
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State | MI
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Zip | 48083-1603
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Country | US
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Telephone | 248-250-9474
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Fax | 248-250-9483
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MY075033
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License Number State | MI
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Legacy Identifiers
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Identifier #1
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Identifier Code | 409819410
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Identifier Type | MEDICAID
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Identifier State | MI
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Identifier Issuer |
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 409819410
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Identifier Type | MEDICAID
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Identifier State | MI
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Identifier Issuer |
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