Healthcare Provider Details

I. General information

NPI: 1528212768
Provider Name (Legal Business Name): PRATIK DIPAKESHWAR BHATTACHARYA MD MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44555 WOODWARD AVE SUITE 104
PONTIAC MI
48341-5031
US

IV. Provider business mailing address

44428 WOODWARD AVE SUITE 101-CREDENTIALING
PONTIAC MI
48341-5009
US

V. Phone/Fax

Practice location:
  • Phone: 248-858-6104
  • Fax: 248-858-6115
Mailing address:
  • Phone: 248-858-6144
  • Fax: 248-858-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number4301088454
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301088454
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: