Provider Demographics
NPI:1669050480
Name:WHEATLEY, MADELINE JOAN (MD)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:JOAN
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:JOAN-DONOVAN-PETER
Other - Last Name:WHEATLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9114 BUFFALO CT
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-1223
Mailing Address - Country:US
Mailing Address - Phone:810-869-1422
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR RM 2110
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1097
Practice Address - Country:US
Practice Address - Phone:734-712-3967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty