Provider Demographics
NPI:1013947522
Name:WIXSON, DESMONDA BRADY (MD)
Entity Type:Individual
Prefix:
First Name:DESMONDA
Middle Name:BRADY
Last Name:WIXSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DESMONDA
Other - Middle Name:L
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4613 W MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-2698
Mailing Address - Country:US
Mailing Address - Phone:269-488-8672
Mailing Address - Fax:269-488-8673
Practice Address - Street 1:4613 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2698
Practice Address - Country:US
Practice Address - Phone:269-488-8672
Practice Address - Fax:269-488-8673
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072883207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4605400Medicaid
MI4605400Medicaid
OH06000041Medicare ID - Type Unspecified