Provider Demographics
NPI:1346378353
Name:DR PADMA AYSOLA MD PC
Entity Type:Organization
Organization Name:DR PADMA AYSOLA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PADMA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYSOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-474-9866
Mailing Address - Street 1:30129 DEER RUN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-6010
Mailing Address - Country:US
Mailing Address - Phone:248-474-9866
Mailing Address - Fax:248-474-9867
Practice Address - Street 1:19930 FARMINGTON RD
Practice Address - Street 2:SUITE C
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1433
Practice Address - Country:US
Practice Address - Phone:248-474-9866
Practice Address - Fax:248-474-9867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPA038608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P21790Medicare ID - Type Unspecified
MIA79244Medicare UPIN