Healthcare Provider Details

I. General information

NPI: 1992921621
Provider Name (Legal Business Name): PRAVEENA SAMPATH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 S LAPEER RD SUITE 134
LAKE ORION MI
48360-1467
US

IV. Provider business mailing address

2111 DORCHESTER DR N
TROY MI
48084-3777
US

V. Phone/Fax

Practice location:
  • Phone: 248-683-3385
  • Fax: 248-683-8441
Mailing address:
  • Phone: 248-614-3114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number4301077694
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: