Provider Demographics
NPI:1619120516
Name:CALISTON, MONETA (MD)
Entity Type:Individual
Prefix:
First Name:MONETA
Middle Name:
Last Name:CALISTON
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 1:31115 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1566
Mailing Address - Country:US
Mailing Address - Phone:248-307-1772
Mailing Address - Fax:248-307-1609
Practice Address - Street 1:31115 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1566
Practice Address - Country:US
Practice Address - Phone:248-307-1772
Practice Address - Fax:248-307-1609
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315036384208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM90210 008Medicare PIN