Healthcare Provider Details

I. General information

NPI: 1750332193
Provider Name (Legal Business Name): GAURAV VASHISHTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27211 LAHSER RD SUITE # 200
SOUTHFIELD MI
48034-8469
US

IV. Provider business mailing address

28411 NORTHWESTERN HWY SUITE #1050
SOUTHFIELD MI
48034-5544
US

V. Phone/Fax

Practice location:
  • Phone: 248-358-4892
  • Fax: 248-358-5125
Mailing address:
  • Phone: 248-354-4709
  • Fax: 248-354-4807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberGV081359
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: