Provider Demographics
NPI:1033225339
Name:VONDRACHEK, ANNE MIYOUNG (MD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MIYOUNG
Last Name:VONDRACHEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:M
Other - Last Name:HERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:58115 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48048-2686
Mailing Address - Country:US
Mailing Address - Phone:586-749-4444
Mailing Address - Fax:586-749-9114
Practice Address - Street 1:58115 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MI
Practice Address - Zip Code:48048-2686
Practice Address - Country:US
Practice Address - Phone:586-749-4444
Practice Address - Fax:586-749-9114
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073327208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4396140Medicaid
MI4396140Medicaid