Provider Demographics
NPI:1619503521
Name:HIGHSMITH, SHANEQUA (MD)
Entity Type:Individual
Prefix:
First Name:SHANEQUA
Middle Name:
Last Name:HIGHSMITH
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 1:1420 WASHINGTON BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1750
Mailing Address - Country:US
Mailing Address - Phone:313-757-2349
Mailing Address - Fax:
Practice Address - Street 1:37595 7 MILE RD STE 340
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1003
Practice Address - Country:US
Practice Address - Phone:734-793-2470
Practice Address - Fax:734-793-2471
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
MI4301510710207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program