Provider Demographics
NPI:1841308996
Name:MISHULIN, SVETLANA M (MD)
Entity type:Individual
Prefix:MRS
First Name:SVETLANA
Middle Name:M
Last Name:MISHULIN
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 1:6604 SHADOWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322
Mailing Address - Country:US
Mailing Address - Phone:248-661-5180
Mailing Address - Fax:248-661-5180
Practice Address - Street 1:2975 N ADAMS ROAD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304
Practice Address - Country:US
Practice Address - Phone:248-645-2900
Practice Address - Fax:248-645-9492
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISM068674OtherBLUE SHIELD TRUST PPO
MIG98045OtherSELECT CARE
MIP103256OtherBLUE CARE NETWORK
G98045Medicare UPIN
MIM77020007Medicare ID - Type Unspecified