Provider Demographics
NPI:1962841544
Name:PANCHBHAIYA, SIRAJ (DPM)
Entity Type:Individual
Prefix:
First Name:SIRAJ
Middle Name:
Last Name:PANCHBHAIYA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20176 LIVERNOIS AVE 100
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1346
Mailing Address - Country:US
Mailing Address - Phone:313-864-7385
Mailing Address - Fax:313-864-7384
Practice Address - Street 1:11900 E 12 MILE RD STE 102
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3487
Practice Address - Country:US
Practice Address - Phone:586-573-7470
Practice Address - Fax:586-573-0850
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002488213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery