Provider Demographics
NPI:1891101432
Name:EZHUTHACHAN, IDIL (MD)
Entity Type:Individual
Prefix:
First Name:IDIL
Middle Name:
Last Name:EZHUTHACHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IDIL
Other - Middle Name:
Other - Last Name:DALOGLU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:130 TOWN CENTER DR
Mailing Address - Street 2:STE 203
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-551-2040
Mailing Address - Fax:248-898-9677
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-551-2040
Practice Address - Fax:248-898-9677
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105270208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics