Provider Demographics
NPI:1942209424
Name:LLEWELYN, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:LLEWELYN
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 1:926 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4323
Mailing Address - Country:US
Mailing Address - Phone:989-753-8453
Mailing Address - Fax:989-753-3519
Practice Address - Street 1:926 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4323
Practice Address - Country:US
Practice Address - Phone:989-753-8453
Practice Address - Fax:989-753-3519
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJL060216174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3153175Medicaid
MI0G36028017Medicare ID - Type Unspecified
MI3153175Medicaid