Provider Demographics
NPI:1689635955
Name:SAMARAPUNGAVAN, DILIP (MD)
Entity Type:Individual
Prefix:
First Name:DILIP
Middle Name:
Last Name:SAMARAPUNGAVAN
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 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3535 W 13 MILE RD STE 644
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-551-1033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065266207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4415344Medicaid
MIBCBSMOtherBCBSM
G92884Medicare UPIN