Provider Demographics
NPI:1710939566
Name:SHIDHAM, VINOD B (MD)
Entity Type:Individual
Prefix:DR
First Name:VINOD
Middle Name:B
Last Name:SHIDHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-745-8555
Mailing Address - Fax:313-966-8989
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:HARPER HOSPITAL PATHOLOGY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:313-745-8555
Practice Address - Fax:313-745-9299
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096896207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32465900Medicaid
002000227EOtherHUMANA
MI0P30630659Medicare PIN
002000227EOtherHUMANA
MI0P30630659Medicare PIN