Provider Demographics
NPI:1235627225
Name:BEDFORD-LYON, NASTASSJA (MD)
Entity type:Individual
Prefix:DR
First Name:NASTASSJA
Middle Name:
Last Name:BEDFORD-LYON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NASTASSJA
Other - Middle Name:
Other - Last Name:LYON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:43151 DALCOMA DR STE 4
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6306
Mailing Address - Country:US
Mailing Address - Phone:586-286-8720
Mailing Address - Fax:586-649-6699
Practice Address - Street 1:2950 KEEWAHDIN RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3526
Practice Address - Country:US
Practice Address - Phone:810-455-1600
Practice Address - Fax:810-455-1620
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301512223207N00000X
MI4301114596390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology