Healthcare Provider Details

I. General information

NPI: 1073134037
Provider Name (Legal Business Name): DIKSHA RATNAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GENERAL ST
LAWRENCE MA
01841-2997
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST STE 9C
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 978-683-4000
  • Fax:
Mailing address:
  • Phone: 313-993-2530
  • Fax: 313-993-7703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1013277
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: