Provider Demographics
NPI:1336133354
Name:PABALAN, JOSEPHINE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPHINE
Middle Name:A
Last Name:PABALAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JASMINE
Other - Middle Name:A
Other - Last Name:PABALAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10850 E TRAVERSE HWY
Mailing Address - Street 2:SUITE 4400
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-1364
Mailing Address - Country:US
Mailing Address - Phone:989-340-1211
Mailing Address - Fax:989-340-1214
Practice Address - Street 1:818 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1446
Practice Address - Country:US
Practice Address - Phone:517-265-0900
Practice Address - Fax:989-340-1214
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJP069482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG61883Medicare UPIN
MIZ16001044Medicare PIN