Provider Demographics
NPI:1861708257
Name:JEFFREY A. LONDON MD PC
Entity type:Organization
Organization Name:JEFFREY A. LONDON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A,
Authorized Official - Last Name:LONDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-646-6659
Mailing Address - Street 1:2075 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3407
Mailing Address - Country:US
Mailing Address - Phone:248-646-6659
Mailing Address - Fax:248-642-8645
Practice Address - Street 1:2075 W BIG BEAVER RD
Practice Address - Street 2:SUITE 520
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3407
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:248-642-8645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040691261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0635747Medicare PIN