Healthcare Provider Details

I. General information

NPI: 1730167552
Provider Name (Legal Business Name): SUDHIR WALAVALKAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22255 GREENFIELD RD 310
SOUTHFIELD MI
48075-3710
US

IV. Provider business mailing address

25925 TELEGRAPH RD 210
SOUTHFIELD MI
48033-2518
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-4990
  • Fax: 248-849-4991
Mailing address:
  • Phone: 248-746-3218
  • Fax: 248-746-0369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301041018
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberSW041018
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: