Provider Demographics
NPI:1891724894
Name:LEHETA, BORIS J (MD)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:J
Last Name:LEHETA
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 1:25100 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4910
Mailing Address - Country:US
Mailing Address - Phone:586-771-7440
Mailing Address - Fax:586-771-9966
Practice Address - Street 1:25100 KELLY RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4910
Practice Address - Country:US
Practice Address - Phone:586-771-7440
Practice Address - Fax:586-771-9966
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBL0496882084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3389375Medicaid
MI0M52180Medicare PIN
MIE64395Medicare ID - Type Unspecified
MIE64395Medicare UPIN