Provider Demographics
NPI:1740390848
Name:MOUDGIL, SHYAM SUNDER (MD)
Entity Type:Individual
Prefix:
First Name:SHYAM
Middle Name:SUNDER
Last Name:MOUDGIL
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 1:25195 KELLY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4909
Mailing Address - Country:US
Mailing Address - Phone:586-777-3370
Mailing Address - Fax:586-777-3380
Practice Address - Street 1:25195 KELLY RD
Practice Address - Street 2:SUITE B
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4909
Practice Address - Country:US
Practice Address - Phone:586-777-3370
Practice Address - Fax:586-777-3380
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301069080207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4399330Medicaid
MI4399330Medicaid
H61266Medicare UPIN