Provider Demographics
NPI:1790897379
Name:WU, JUSTINE PEEN (MD)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:PEEN
Last Name:WU
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 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:20321 FARMINGTON ROAD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:248-473-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07613000207Q00000X
MI4301076163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0127353Medicaid
NJP00953358OtherRR MCR PTAN
NJ117045DFFMedicare PIN
NJ0127353Medicaid
NJP00953358OtherRR MCR PTAN
NJ117045A02Medicare PIN