Provider Demographics
NPI:1013128925
Name:JNANANAND, NAYANTARA (MD)
Entity Type:Individual
Prefix:DR
First Name:NAYANTARA
Middle Name:
Last Name:JNANANAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50936 RICHARD DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1192
Mailing Address - Country:US
Mailing Address - Phone:248-910-4123
Mailing Address - Fax:888-378-0244
Practice Address - Street 1:8552 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1310
Practice Address - Country:US
Practice Address - Phone:248-910-4123
Practice Address - Fax:888-378-0244
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1013128925Medicaid
MI1104840529OtherBCBSM - BRONSON PRACTICE MANAGEMENT
MIM32030168OtherMEDICARE
MI1104840529OtherBCBSM - BRONSON PRACTICE MANAGEMENT