Provider Demographics
NPI:1235192402
Name:PERSAUD, MICHAEL V (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:V
Last Name:PERSAUD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 TOWER RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049
Mailing Address - Country:US
Mailing Address - Phone:712-255-1414
Mailing Address - Fax:
Practice Address - Street 1:101 TOWER RD
Practice Address - Street 2:SUITE 105
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049
Practice Address - Country:US
Practice Address - Phone:712-255-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01980207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0223974Medicaid
IA0223974Medicaid
SDS1020701Medicare PIN
IAI21432Medicare PIN