Provider Demographics
NPI:1639444748
Name:ICECREAMWALA, DEVIKA (MD)
Entity Type:Individual
Prefix:
First Name:DEVIKA
Middle Name:
Last Name:ICECREAMWALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEVIKA
Other - Middle Name:
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4201 ST. ANTOINE - UHC 5D - MAILBOX #226
Mailing Address - Street 2:UNIVERSITY PEDIATRICIANS
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-4405
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:4000 DUBLIN BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-3113
Practice Address - Country:US
Practice Address - Phone:925-875-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301103562207N00000X, 207NP0225X, 208000000X
CA148974207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics