Provider Demographics
NPI:1376709493
Name:AMIN, RUPEN SURESH (MD)
Entity Type:Individual
Prefix:DR
First Name:RUPEN
Middle Name:SURESH
Last Name:AMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 KIRTS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4135
Mailing Address - Country:US
Mailing Address - Phone:248-434-6169
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:2360 GUS THOMASSON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228
Practice Address - Country:US
Practice Address - Phone:214-301-7071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101248233207Q00000X
TXS6111207Q00000X
NY25MA11713300207Q00000X
IN01081343A207Q00000X
NY320993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1376709493Medicaid
VAC06778OtherGROUP PTAN