Provider Demographics
NPI:1346433422
Name:FEDERMAN, ALEXIS WAGMAN (DO)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:WAGMAN
Last Name:FEDERMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:LEIGH
Other - Last Name:WAGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1385 E 12 MILE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2618
Mailing Address - Country:US
Mailing Address - Phone:248-399-6090
Mailing Address - Fax:248-399-5282
Practice Address - Street 1:1385 E 12 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071
Practice Address - Country:US
Practice Address - Phone:248-399-6090
Practice Address - Fax:248-399-5282
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10098207R00000X
MI5101016164207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine