Provider Demographics
NPI:1639119373
Name:MANSABDAR, MADHURA (MD)
Entity Type:Individual
Prefix:
First Name:MADHURA
Middle Name:
Last Name:MANSABDAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W BROADWAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2446
Mailing Address - Country:US
Mailing Address - Phone:989-772-9523
Mailing Address - Fax:989-772-9052
Practice Address - Street 1:411 W BROADWAY ST
Practice Address - Street 2:SUITE A
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2402
Practice Address - Country:US
Practice Address - Phone:989-772-9523
Practice Address - Fax:989-772-9052
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4565207-10Medicaid
MI1007076OtherMCLAREN HEALTH PLAN
MI1103710561OtherBCBSM
MI0988830OtherHEALTHPLUS
MI200000008878OtherPHP COMMERCIAL
MI4270238-10Medicaid
MI110214572Medicare PIN
MI0988830OtherHEALTHPLUS
MI4565207-10Medicaid
MIM17400026Medicare PIN