MEDICARE: DR. DAFINA WISE ALLEN M.D.

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	207Q00000X	Family Medicine Physician	036.134077	IL
2	207Q00000X	Family Medicine Physician	4301108583	MI

General Provider Information

NPI Number	:	1811288400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAFINA WISE ALLEN M.D.

Provider Business Mailing Address
First Line	:	1447 N HARRISON ST
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48602-4727
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3875 BAY RD STE 2N
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48603-2423
Country	:	US
Telephone Number	:	989-792-1375
Fax Number	:

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

Provider Enumeration Date	:	04/29/2011
Last Update Date	:	01/07/2020

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