Provider Demographics
NPI:1689638330
Name:MONDRUSOVA, OLGA (MD)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:MONDRUSOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:40015 GRAND RIVER AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2160
Mailing Address - Country:US
Mailing Address - Phone:248-473-8580
Mailing Address - Fax:248-474-4208
Practice Address - Street 1:40015 GRAND RIVER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2160
Practice Address - Country:US
Practice Address - Phone:248-473-8580
Practice Address - Fax:248-474-4208
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301071758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H50488Medicare UPIN
0F37239006Medicare ID - Type Unspecified