Provider Demographics
NPI:1982878542
Name:BANERJEE, SUDESHNA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDESHNA
Middle Name:
Last Name:BANERJEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUDESHNA
Other - Middle Name:
Other - Last Name:BANDYOPADHYAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-745-8555
Mailing Address - Fax:313-966-8989
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:313-745-8555
Practice Address - Fax:313-966-8989
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078387207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630543Medicare PIN