Healthcare Provider Details

I. General information

NPI: 1265091045
Provider Name (Legal Business Name): MAYURI SAXENA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

44405 WOODWARD AVE MEDICAL EDUCATION - H23
PONTIAC MI
48341
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1328
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351045042
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301505707
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: