Provider Demographics
NPI:1831172303
Name:DIWAN, PAMILA (MD)
Entity type:Individual
Prefix:DR
First Name:PAMILA
Middle Name:
Last Name:DIWAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30555 SOUTHFIELD RD
Mailing Address - Street 2:STE 180
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1221
Mailing Address - Country:US
Mailing Address - Phone:248-644-8220
Mailing Address - Fax:248-644-7338
Practice Address - Street 1:30555 SOUTHFIELD RD
Practice Address - Street 2:STE 180
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1221
Practice Address - Country:US
Practice Address - Phone:248-644-8220
Practice Address - Fax:248-644-7338
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301039114207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1565615Medicaid
MI0630020Medicare ID - Type Unspecified
MI1565615Medicaid