Provider Demographics
NPI:1255323747
Name:DEWAR, SHENBAGAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SHENBAGAM
Middle Name:
Last Name:DEWAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHENBAGAM
Other - Middle Name:
Other - Last Name:VEERAPUTHIRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD,
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:4260 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-2700
Practice Address - Country:US
Practice Address - Phone:734-764-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108515207Q00000X, 207RG0300X, 207QG0300X
MA230753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A871530Medicaid
CAGR0003490Medicaid
CAGR0003490Medicaid
CAZZZ86396ZMedicare ID - Type UnspecifiedGROUP
CAGR0003490Medicaid