Provider Demographics
NPI:1073599353
Name:DEDICATORIA, VIRGINIA (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:DEDICATORIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 DAVENPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3365
Mailing Address - Country:US
Mailing Address - Phone:989-790-0100
Mailing Address - Fax:989-790-0241
Practice Address - Street 1:3424 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3365
Practice Address - Country:US
Practice Address - Phone:989-790-0100
Practice Address - Fax:989-790-0241
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4552011Medicaid
MIP00053088OtherRR MEDICARE
MI0N73640Medicare ID - Type Unspecified
MIP00053088OtherRR MEDICARE