Provider Demographics
NPI:1083614002
Name:ROYCHOUDHURY, PROMITA (MD)
Entity Type:Individual
Prefix:
First Name:PROMITA
Middle Name:
Last Name:ROYCHOUDHURY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PROMITA
Other - Middle Name:
Other - Last Name:BANERJEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:15990 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4826
Mailing Address - Country:US
Mailing Address - Phone:248-849-4226
Mailing Address - Fax:248-849-4240
Practice Address - Street 1:210 N LAFAYETTE
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178
Practice Address - Country:US
Practice Address - Phone:248-437-1744
Practice Address - Fax:248-446-2420
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079465207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI471590310Medicaid
MI0F36020016Medicare ID - Type Unspecified
MIH76067Medicare UPIN