Provider Demographics
NPI:1386626547
Name:WISNIEWSKI, LEANNE M (DO)
Entity Type:Individual
Prefix:DR
First Name:LEANNE
Middle Name:M
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LEANNE
Other - Middle Name:MARIE
Other - Last Name:DEWAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:27332 WOODWARD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-0927
Mailing Address - Country:US
Mailing Address - Phone:248-543-1545
Mailing Address - Fax:246-543-8638
Practice Address - Street 1:27332 WOODWARD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0927
Practice Address - Country:US
Practice Address - Phone:248-543-1545
Practice Address - Fax:246-543-8638
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013066208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H07419Medicare UPIN
MIOM91370Medicare ID - Type Unspecified