Healthcare Provider Details

I. General information

NPI: 1508445867
Provider Name (Legal Business Name): DHIR PATWA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4717 SAINT ANTOINE ST
DETROIT MI
48201-1423
US

IV. Provider business mailing address

400 MACK AVE
DETROIT MI
48201-2136
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301514090
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: