Provider Demographics
NPI:1356387708
Name:PODESZWA, TED (DO)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:PODESZWA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:28711 8 MILE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2040
Mailing Address - Country:US
Mailing Address - Phone:248-474-2220
Mailing Address - Fax:248-474-5273
Practice Address - Street 1:28711 8 MILE RD
Practice Address - Street 2:SUITE D
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2040
Practice Address - Country:US
Practice Address - Phone:248-474-2220
Practice Address - Fax:248-474-5273
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101005210207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4102835OtherAETNA
MIP46981OtherBLUE CROSS
MI2875701Medicaid
MIB4340OtherMCARE
MIB4340OtherMCARE
MI2875701Medicaid