Provider Demographics
NPI:1376036152
Name:MALI, ANKITA S (RPT)
Entity Type:Individual
Prefix:
First Name:ANKITA
Middle Name:S
Last Name:MALI
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 FORT ST STE 101
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2191
Mailing Address - Country:US
Mailing Address - Phone:646-287-9633
Mailing Address - Fax:
Practice Address - Street 1:2075 FORT ST STE 101
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2191
Practice Address - Country:US
Practice Address - Phone:734-564-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014946208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicaid