Healthcare Provider Details

I. General information

NPI: 1548014889
Provider Name (Legal Business Name): NISHTA POLAM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 WILSON RD RM A233
EAST LANSING MI
48824-6410
US

IV. Provider business mailing address

4540 HUNT CLUB DR APT 1A
YPSILANTI MI
48197-9097
US

V. Phone/Fax

Practice location:
  • Phone: 517-353-4362
  • Fax: 517-432-0927
Mailing address:
  • Phone: 804-332-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5151016993
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: