Provider Demographics
NPI:1356409973
Name:KHALSA, GURUDARSHAN S (MD)
Entity type:Individual
Prefix:
First Name:GURUDARSHAN
Middle Name:S
Last Name:KHALSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2821
Mailing Address - Country:US
Mailing Address - Phone:248-541-4834
Mailing Address - Fax:
Practice Address - Street 1:484 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2821
Practice Address - Country:US
Practice Address - Phone:248-541-4834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK7576486OtherDEA
A76047Medicare UPIN