Provider Demographics
NPI:1467447441
Name:MENDIRATTA, MADHU (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHU
Middle Name:
Last Name:MENDIRATTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MADHU
Other - Middle Name:
Other - Last Name:RAPOOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26699 WEST 12 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1754
Mailing Address - Country:US
Mailing Address - Phone:248-945-9370
Mailing Address - Fax:248-945-9377
Practice Address - Street 1:26699 WEST 12 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1754
Practice Address - Country:US
Practice Address - Phone:248-945-9370
Practice Address - Fax:248-945-9377
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010485202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383583448OtherPPOM
MI2606309652OtherBC
MI2606309652OtherBC
G14812Medicare UPIN