Healthcare Provider Details

I. General information

NPI: 1013925858
Provider Name (Legal Business Name): SUDIPTA DHAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 UNION LAKE RD SUITE 110
COMMERCE TOWNSHIP MI
48382-3500
US

IV. Provider business mailing address

4865 E STRONG CT
ORCHARD LAKE MI
48323-1578
US

V. Phone/Fax

Practice location:
  • Phone: 248-366-0101
  • Fax: 248-366-0108
Mailing address:
  • Phone: 248-738-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberSD074233
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: