Provider Demographics
NPI:1093875536
Name:MUTHUSWAMI, SUBBANA G (MD)
Entity Type:Individual
Prefix:
First Name:SUBBANA
Middle Name:G
Last Name:MUTHUSWAMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2603 ELECTRIC AVE
Mailing Address - Street 2:#1
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-987-5252
Mailing Address - Fax:810-987-2120
Practice Address - Street 1:2603 ELECTRIC AVE
Practice Address - Street 2:#1
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-987-5252
Practice Address - Fax:810-987-2120
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301033903207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2109010Medicaid
A73999Medicare UPIN
MI2109010Medicaid