Healthcare Provider Details

I. General information

NPI: 1790316354
Provider Name (Legal Business Name): DYANA KOTANI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2020
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4995 HIGHLAND RD
WATERFORD MI
48328-1143
US

IV. Provider business mailing address

37792 BLOSSOM LN
FARMINGTON HILLS MI
48331-1734
US

V. Phone/Fax

Practice location:
  • Phone: 248-674-2261
  • Fax:
Mailing address:
  • Phone: 248-535-4482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302411950
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: