Healthcare Provider Details

I. General information

NPI: 1700827680
Provider Name (Legal Business Name): VASAN H DESHIKACHAR M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11803 GRAND RIVER AVE
DETROIT MI
48204-1810
US

IV. Provider business mailing address

11803 GRAND RIVER AVE
DETROIT MI
48204-1810
US

V. Phone/Fax

Practice location:
  • Phone: 313-491-5544
  • Fax: 313-491-7433
Mailing address:
  • Phone: 313-491-5544
  • Fax: 313-491-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4301062217
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: