Provider Demographics
NPI:1750332193
Name:VASHISHTA, GAURAV (MD)
Entity Type:Individual
Prefix:
First Name:GAURAV
Middle Name:
Last Name:VASHISHTA
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 1:28411 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE #1050
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5544
Mailing Address - Country:US
Mailing Address - Phone:248-354-4709
Mailing Address - Fax:248-354-4807
Practice Address - Street 1:27211 LAHSER RD
Practice Address - Street 2:SUITE # 200
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8469
Practice Address - Country:US
Practice Address - Phone:248-358-4892
Practice Address - Fax:248-358-5125
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIGV081359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110F336360OtherBCBSM
MI1346398971OtherGROUP NPI
MI205485614OtherTAX ID
MI4301081359OtherLICENSE
MI207R00000XOtherTAXOMOMY
MI104934122Medicaid
MI0P41360025Medicare PIN
MI4301081359OtherLICENSE