Provider Demographics
NPI:1851327159
Name:MRIDHA, DEBASISH (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBASISH
Middle Name:
Last Name:MRIDHA
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 1:4705 TOWNE CENTRE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2821
Mailing Address - Country:US
Mailing Address - Phone:989-799-2770
Mailing Address - Fax:989-799-2737
Practice Address - Street 1:4705 TOWNE CTR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2818
Practice Address - Country:US
Practice Address - Phone:989-799-2770
Practice Address - Fax:989-799-2737
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDM0667282084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104695041Medicaid
MI0P07920Medicare ID - Type Unspecified
MIG99891Medicare UPIN