Healthcare Provider Details

I. General information

NPI: 1043425895
Provider Name (Legal Business Name): ISHANI DALAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

43680 LAURELWOOD DR
CANTON MI
48187-4916
US

V. Phone/Fax

Practice location:
  • Phone: 313-282-1440
  • Fax:
Mailing address:
  • Phone: 734-708-0576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number4301088629
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: