Provider Demographics
NPI:1770650889
Name:MADISHETTY, SAMYUKTHA R I (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMYUKTHA
Middle Name:R
Last Name:MADISHETTY
Suffix:I
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 1:24100 OXFORD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2481
Mailing Address - Country:US
Mailing Address - Phone:734-397-3928
Mailing Address - Fax:313-278-5846
Practice Address - Street 1:24100 OXFORD ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-561-3000
Practice Address - Fax:313-561-4831
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108281851OtherBCN IND
MI1108281851OtherBCBS IND
MIP00470436OtherRAILROAD MEDICARE IND PIN
MII46399OtherHAP
MIP43920001Medicare PIN