Provider Demographics
NPI:1962630806
Name:PATHADAN, TINA PAUL (DO)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:PAUL
Last Name:PATHADAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17187 SCHAEFER HWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-4132
Mailing Address - Country:US
Mailing Address - Phone:313-367-2767
Mailing Address - Fax:313-367-2818
Practice Address - Street 1:27970 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3767
Practice Address - Country:US
Practice Address - Phone:248-737-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101018954208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation