Provider Demographics
NPI:1013925858
Name:DHAR, SUDIPTA (MD)
Entity Type:Individual
Prefix:
First Name:SUDIPTA
Middle Name:
Last Name:DHAR
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 1:4865 E STRONG CT
Mailing Address - Street 2:
Mailing Address - City:ORCHARD LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1578
Mailing Address - Country:US
Mailing Address - Phone:248-738-5414
Mailing Address - Fax:
Practice Address - Street 1:2900 UNION LAKE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-3500
Practice Address - Country:US
Practice Address - Phone:248-366-0101
Practice Address - Fax:248-366-0108
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISD074233208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISD074233OtherMICHIGAN LICENSE
MI4477955Medicaid