Provider Demographics
NPI:1518978394
Name:MENDIRATTA, KANWAR VIRENDER (MD)
Entity Type:Individual
Prefix:DR
First Name:KANWAR
Middle Name:VIRENDER
Last Name:MENDIRATTA
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 1:26699 W 12 MILE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-7814
Mailing Address - Country:US
Mailing Address - Phone:248-358-0011
Mailing Address - Fax:248-358-1491
Practice Address - Street 1:26699 W 12 MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7814
Practice Address - Country:US
Practice Address - Phone:248-358-0011
Practice Address - Fax:248-358-1491
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKM041292207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
111193OtherCARE CHOICES
2906303621OtherBLUE CROSS BLUE SHIELD
C1457OtherMCARE
14765OtherHEALTH PLAN OF MICHIGAN
2149224OtherAETNA
MI3127120Medicaid
C1457OtherMCARE
MI3127120Medicaid