Provider Demographics
NPI:1245321454
Name:PATHAK, PRITI (MD)
Entity type:Individual
Prefix:
First Name:PRITI
Middle Name:
Last Name:PATHAK
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:PO BOX 30161
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-7661
Mailing Address - Country:US
Mailing Address - Phone:517-887-4302
Mailing Address - Fax:517-887-4625
Practice Address - Street 1:2316 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3152
Practice Address - Country:US
Practice Address - Phone:517-887-4302
Practice Address - Fax:517-887-4625
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI774276133Medicare ID - Type UnspecifiedST LAWRENCE CLINIC
G60641Medicare UPIN
MIC36051029Medicare ID - Type UnspecifiedPERSONAL PROVIDER ID