Provider Demographics
NPI:1790755049
Name:PRADHAN, JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:PRADHAN
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 1:75 BARCLAY CIR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5820
Mailing Address - Country:US
Mailing Address - Phone:248-246-1127
Mailing Address - Fax:248-246-0704
Practice Address - Street 1:75 BARCLAY CIR
Practice Address - Street 2:SUITE 230
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5820
Practice Address - Country:US
Practice Address - Phone:248-246-1127
Practice Address - Fax:248-246-0704
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJP071846207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P01030OtherMEDICARE GROUP NUMBER
MI1108297492OtherBCBS NUMBERS
MI4449674Medicaid
MI0P01030OtherMEDICARE GROUP NUMBER
MI4449674Medicaid