Provider Demographics
NPI:1508968264
Name:PERRY, MONA (MD)
Entity Type:Individual
Prefix:DR
First Name:MONA
Middle Name:
Last Name:PERRY
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 1:6379 SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-8706
Mailing Address - Country:US
Mailing Address - Phone:810-735-7847
Mailing Address - Fax:810-735-7159
Practice Address - Street 1:6379 SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8706
Practice Address - Country:US
Practice Address - Phone:810-735-7847
Practice Address - Fax:810-735-7159
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063150207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4194753Medicaid
MI4194753Medicaid
MIM23560118Medicare PIN