Provider Demographics
NPI:1336405554
Name:MITSUYA, JENNIFER B (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:MITSUYA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:BORDATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:26901 BEAUMONT BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033
Mailing Address - Country:US
Mailing Address - Phone:947-522-1858
Mailing Address - Fax:248-350-4123
Practice Address - Street 1:3535 W 13 MILE RD STE 707
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-551-0487
Practice Address - Fax:248-551-3696
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010198462080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology