Provider Demographics
NPI:1952315699
Name:DIXIT, PURUSHOTTAM K (MD)
Entity Type:Individual
Prefix:
First Name:PURUSHOTTAM
Middle Name:K
Last Name:DIXIT
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:130 TOWN CENTER DR STE 203
Mailing Address - Street 2:BEAUMONT MEDICAL STAFF AFFAIRS
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-585-8216
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:BEAUMONT HOSPITAL - RO
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-585-8271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010720462085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI489597310Medicaid
PD072046OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262300OtherBLUE CROSS-BLUE CROSS
PD072046OtherCHAMPUS-CHAMPUS
PD072046OtherCHAMPUS-CHAMPUS
PD072046OtherCOMMERCIAL-COMMERCIAL NUMBER