Provider Demographics
NPI:1902380652
Name:BHANDARKAR, ANKUSH SURESH
Entity Type:Individual
Prefix:
First Name:ANKUSH
Middle Name:SURESH
Last Name:BHANDARKAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 WOODWARD AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2027
Mailing Address - Country:US
Mailing Address - Phone:313-264-3781
Mailing Address - Fax:
Practice Address - Street 1:4160 WOODWARD AVE FL 2
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2027
Practice Address - Country:US
Practice Address - Phone:313-264-3781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB536067011648OtherDRIVING LICENSE