Provider Demographics
NPI:1457681074
Name:GWENDOLYN WASHINGTON M.D. PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GWENDOLYN WASHINGTON M.D. PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-350-8895
Mailing Address - Street 1:29255 NORTHWESTERN HWY STE 105
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5740
Mailing Address - Country:US
Mailing Address - Phone:248-350-8895
Mailing Address - Fax:248-350-8894
Practice Address - Street 1:29255 NORTHWESTERN HWY STE 105
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5740
Practice Address - Country:US
Practice Address - Phone:248-350-8895
Practice Address - Fax:248-350-8894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2103295Medicaid
MIA76415Medicare UPIN