Basic Information
Provider Information
NPI: 1003294455
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RAYMUNDO
FirstName: STEPHANIE-GRACE
MiddleName: ABINOJA
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 45410 ADDINGTON LN
Address2:  
City: NOVI
State: MI
PostalCode: 483743763
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 505 S MAIN ST STE 525
Address2:  
City: ORANGE
State: CA
PostalCode: 92868
CountryCode: US
TelephoneNumber: 7144565631
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/18/2015
LastUpdateDate: 07/05/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000XA146261CAY Allopathic & Osteopathic PhysiciansPediatrics 
390200000X CAN Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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