Healthcare Provider Details

I. General information

NPI: 1992899546
Provider Name (Legal Business Name): MANILAL O MEWADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 WALLI STRASSE SUITE C
BURTON MI
48509-1729
US

IV. Provider business mailing address

4001 WALLI STRASSE SUITE C
BURTON MI
48509-1729
US

V. Phone/Fax

Practice location:
  • Phone: 810-743-5400
  • Fax: 810-743-5474
Mailing address:
  • Phone: 810-743-5400
  • Fax: 810-743-5474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301041950
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301041950
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMM041950
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: