Healthcare Provider Details

I. General information

NPI: 1205836137
Provider Name (Legal Business Name): SHYLAJA GONTINA-KHATIWALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 09/27/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 N RUSHTON RD
SOUTH LYON MI
48178-8849
US

IV. Provider business mailing address

9600 N RUSHTON RD
SOUTH LYON MI
48178-8849
US

V. Phone/Fax

Practice location:
  • Phone: 248-721-1510
  • Fax:
Mailing address:
  • Phone: 248-721-1510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301076421
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number4301076421
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: