Provider Demographics
NPI:1144323296
Name:D'SA, IRENE M (MD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:M
Last Name:D'SA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
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Mailing Address - Street 1:49114 DRIFTWOOD DR
Mailing Address - Street 2:STE. 101
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-1742
Mailing Address - Country:US
Mailing Address - Phone:586-254-1282
Mailing Address - Fax:
Practice Address - Street 1:49114 DRIFTWOOD DR
Practice Address - Street 2:STE. 101
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-1742
Practice Address - Country:US
Practice Address - Phone:586-254-1282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI37237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII49214Medicare UPIN
N8489006Medicare ID - Type Unspecified