Provider Demographics
NPI:1811939572
Name:FAN, WILEY (DO)
Entity type:Individual
Prefix:
First Name:WILEY
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28080 GRAND RIVER AVE STE 306N
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:947-521-8314
Practice Address - Fax:248-478-8864
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007795207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4036071OtherAETNA
MIP49606OtherBLUE CROSS
MI2869034Medicaid
MI126488OtherCARE CHOICES
MI5634383OtherBLUE CROSS
MI126488OtherCARE CHOICES
MI4036071OtherAETNA