Provider Demographics
NPI:1790010544
Name:IGNATIOS VOUDOUKIS MD PC
Entity Type:Organization
Organization Name:IGNATIOS VOUDOUKIS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IGNATIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:VOUDOUKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-831-4600
Mailing Address - Street 1:4727 SAINT ANTOINE ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1461
Mailing Address - Country:US
Mailing Address - Phone:313-831-4600
Mailing Address - Fax:313-831-1220
Practice Address - Street 1:4727 SAINT ANTOINE ST
Practice Address - Street 2:SUITE 402
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1461
Practice Address - Country:US
Practice Address - Phone:313-831-4600
Practice Address - Fax:313-831-1220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028811207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1026899Medicaid
MI1026899Medicaid