Provider Demographics
NPI:1659869139
Name:PHALA, SEFAKO (MD)
Entity Type:Individual
Prefix:DR
First Name:SEFAKO
Middle Name:
Last Name:PHALA
Suffix:
Gender:M
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0779
Mailing Address - Country:US
Mailing Address - Phone:989-671-9153
Mailing Address - Fax:989-671-9253
Practice Address - Street 1:4040 N EUCLID AVE STE B
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2493
Practice Address - Country:US
Practice Address - Phone:989-671-9153
Practice Address - Fax:989-671-9253
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301505147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program