Provider Demographics
NPI:1720021900
Name:DIVI, THULASI S (MD)
Entity Type:Individual
Prefix:
First Name:THULASI
Middle Name:S
Last Name:DIVI
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 1:20755 GREENFIELD RD
Mailing Address - Street 2:SUITE 1004
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5403
Mailing Address - Country:US
Mailing Address - Phone:248-424-5090
Mailing Address - Fax:248-424-5091
Practice Address - Street 1:20755 GREENFIELD RD
Practice Address - Street 2:SUITE 1004
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5403
Practice Address - Country:US
Practice Address - Phone:248-424-5090
Practice Address - Fax:248-424-5091
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4226454Medicaid
MIBD6143147OtherDEA NUMBER
MI0N14510Medicare ID - Type Unspecified
MI4226454Medicaid