Provider Demographics
NPI:1326219312
Name:PANDYA, SHARDUL HARENDRA (RPT)
Entity Type:Individual
Prefix:MR
First Name:SHARDUL
Middle Name:HARENDRA
Last Name:PANDYA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21647 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2795
Mailing Address - Country:US
Mailing Address - Phone:586-264-0388
Mailing Address - Fax:586-757-0397
Practice Address - Street 1:21647 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2795
Practice Address - Country:US
Practice Address - Phone:586-757-0317
Practice Address - Fax:586-757-0397
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005660174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4630118Medicaid
N90250Medicare PIN