Provider Demographics
NPI:1104865443
Name:AGNELLO-DIMITRIJEVIC, WILMA (MD)
Entity Type:Individual
Prefix:
First Name:WILMA
Middle Name:
Last Name:AGNELLO-DIMITRIJEVIC
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 1:43421 GARFIELD RD
Mailing Address - Street 2:STE1
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1133
Mailing Address - Country:US
Mailing Address - Phone:586-286-5500
Mailing Address - Fax:586-286-0900
Practice Address - Street 1:15855 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-263-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIWA0583162084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1104865443Medicaid
MI3290951Medicaid
MIG35382Medicare UPIN
MI0N31900022Medicare PIN
MI1104865443Medicaid