Provider Demographics
NPI:1215195748
Name:WOLDIE, INDRYAS LEMMA (MD)
Entity type:Individual
Prefix:
First Name:INDRYAS
Middle Name:LEMMA
Last Name:WOLDIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5977
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:4201 ST. ANTOINE
Practice Address - Street 2:SUITE 7B
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-2554
Practice Address - Fax:313-993-0295
Is Sole Proprietor?:No
Enumeration Date:2008-05-31
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088450207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630907Medicare PIN