MEDICARE: HARRIETTA CHRISTODOULOS DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	5101015544	MI

General Provider Information

NPI Number	:	1033111653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HARRIETTA CHRISTODOULOS DO

Provider Business Mailing Address
First Line	:	804 SERVICE RD STE A109B
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48824-7015
Country	:	US
Telephone Number	:	517-364-5440
Fax Number	:	517-364-5409

Provider Business Practice Location Address
First Line	:	1200 E MICHIGAN AVE STE 145
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48912-1897
Country	:	US
Telephone Number	:	517-364-5440
Fax Number	:	517-364-5409

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	03/15/2023

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