Healthcare Provider Details

I. General information

NPI: 1780746602
Provider Name (Legal Business Name): VR JASTY MD PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 12/30/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 UNIVERSITY DR
AUBURN HILLS MI
48326-2675
US

IV. Provider business mailing address

6720 BIRMINGHAM CLUB DR
BLOOMFIELD HILLS MI
48301-3119
US

V. Phone/Fax

Practice location:
  • Phone: 586-484-7159
  • Fax: 248-385-5771
Mailing address:
  • Phone: 586-484-7159
  • Fax: 248-385-5771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number4301057306
License Number StateMI

VIII. Authorized Official

Name: DR. VENKATA RAMANA JASTY
Title or Position: PSYCHIATRIST
Credential: MD
Phone: 586-484-7159