Provider Demographics
NPI:1003847617
Name:MENDIRATTA, SURINDER (MD)
Entity Type:Individual
Prefix:
First Name:SURINDER
Middle Name:
Last Name:MENDIRATTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SURINDER
Other - Middle Name:
Other - Last Name:MENDIRATTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:20905 GREENFIELD RD
Mailing Address - Street 2:SUITE 502
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5360
Mailing Address - Country:US
Mailing Address - Phone:248-395-2888
Mailing Address - Fax:248-395-2891
Practice Address - Street 1:20905 GREENFIELD RD
Practice Address - Street 2:SUITE 502
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5360
Practice Address - Country:US
Practice Address - Phone:248-395-2888
Practice Address - Fax:248-395-2891
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060904207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4299782Medicaid
MI4299782Medicaid
MIG22306Medicare UPIN