Provider Demographics
NPI:1932102423
Name:WIZENBERG, THEODORE A (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:A
Last Name:WIZENBERG
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 1:31151 WESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1471
Mailing Address - Country:US
Mailing Address - Phone:248-661-9125
Mailing Address - Fax:
Practice Address - Street 1:23901 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-6035
Practice Address - Country:US
Practice Address - Phone:248-357-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038081207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1106338231OtherBCBS
MIA77757Medicare UPIN
MI0N95670Medicare ID - Type UnspecifiedGROUP NUMBER