Provider Demographics
NPI:1487638755
Name:CITRON, ALISSA N (DO)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:N
Last Name:CITRON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29645 W 14 MILE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1666
Practice Address - Country:US
Practice Address - Phone:248-254-6000
Practice Address - Fax:248-254-6001
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1487638755Medicaid
MII20556Medicare UPIN
MI1487638755Medicaid
MI0M92440044Medicare PIN