Provider Demographics
NPI:1841274032
Name:CHISA, NELDAGAE S (MD)
Entity type:Individual
Prefix:
First Name:NELDAGAE
Middle Name:S
Last Name:CHISA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:36700 WOODWARD AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-0926
Mailing Address - Country:US
Mailing Address - Phone:248-647-5750
Mailing Address - Fax:248-647-6008
Practice Address - Street 1:36700 WOODWARD AVE
Practice Address - Street 2:STE 203
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-0926
Practice Address - Country:US
Practice Address - Phone:248-647-5750
Practice Address - Fax:248-647-6008
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301022545207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B44132Medicare UPIN