Provider Demographics
NPI:1255310397
Name:MATHARU, JEETENDER SINGH (MD)
Entity Type:Individual
Prefix:DR
First Name:JEETENDER
Middle Name:SINGH
Last Name:MATHARU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7250 DIXIE HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5108
Mailing Address - Country:US
Mailing Address - Phone:248-620-3500
Mailing Address - Fax:248-620-3503
Practice Address - Street 1:7250 DIXIE HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5108
Practice Address - Country:US
Practice Address - Phone:248-620-3500
Practice Address - Fax:248-620-3503
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4483424Medicaid
MI0806300321OtherBCBS
MI0806300321OtherBCBS
0N67480Medicare ID - Type Unspecified