=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396881827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARKSTON MEDICAL CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5790 S MAIN STREET STE J
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-625-8220
-----------------------------------------------------
Fax | 248-625-6646
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5790 S MAIN STREET STE J
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-625-8220
-----------------------------------------------------
Fax | 248-625-6646
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TARLIKA C DHABUWALA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 248-625-8220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | TD040084
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------