Provider Demographics
NPI:1760861777
Name:MADUT, NYEBOL B (DO)
Entity type:Individual
Prefix:DR
First Name:NYEBOL
Middle Name:B
Last Name:MADUT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NYEBOL
Other - Middle Name:BUOK
Other - Last Name:MADUT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:7740 HERITAGE DR.
Mailing Address - Street 2:APT. 5
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-6820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5525 S MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911
Practice Address - Country:US
Practice Address - Phone:517-913-3888
Practice Address - Fax:517-394-7483
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine