Provider Demographics
NPI:1477120079
Name:BILTIBO, LIDIYA AYELE (MD)
Entity Type:Individual
Prefix:MS
First Name:LIDIYA
Middle Name:AYELE
Last Name:BILTIBO
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 1:1824 KIRTS BLVD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:240-310-5014
Mailing Address - Fax:
Practice Address - Street 1:DMC SINAI GRACE HOSPITAL
Practice Address - Street 2:4201 ST ANTOINE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:416-848-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-09-29
Deactivation Date:2021-08-30
Deactivation Code:
Reactivation Date:2021-09-29
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4351048229390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program