Provider Demographics
NPI:1598980567
Name:WEST, MARKEETA
Entity Type:Individual
Prefix:
First Name:MARKEETA
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:
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:947-522-1848
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:15777 NORTHLINE RD STE 200
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2354
Practice Address - Country:US
Practice Address - Phone:734-246-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01209208000000X
SC34176208000000X
MI4301085607208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC99843365OtherMEDICARE PIN
SCSC99845019OtherMEDICARE PIN
SC341767Medicaid