Provider Demographics
NPI:1598046153
Name:THEPSONGWAJJA, JET (MD)
Entity Type:Individual
Prefix:
First Name:JET
Middle Name:
Last Name:THEPSONGWAJJA
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:1251 LAKEPOINTE ST
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:SUITE 332
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2167
Practice Address - Country:US
Practice Address - Phone:313-343-7849
Practice Address - Fax:313-343-7378
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301099550208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery