Provider Demographics
NPI:1245895606
Name:ZHAO, DONG FANG (MD)
Entity type:Individual
Prefix:DR
First Name:DONG FANG
Middle Name:
Last Name:ZHAO
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 1:15001 KERCHEVAL AVE PMB 502
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1361
Mailing Address - Country:US
Mailing Address - Phone:810-322-7952
Mailing Address - Fax:
Practice Address - Street 1:15001 KERCHEVAL AVE PMB 502
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-1361
Practice Address - Country:US
Practice Address - Phone:810-322-7952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2022-07-12
Deactivation Date:2019-12-16
Deactivation Code:
Reactivation Date:2020-02-13
Provider Licenses
StateLicense IDTaxonomies
MI4301505594208D00000X
MI4351045559390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice