Provider Demographics
NPI:1356381347
Name:PANDYA, HARIVALLABH D (MD)
Entity type:Individual
Prefix:
First Name:HARIVALLABH
Middle Name:D
Last Name:PANDYA
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 1:28300 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1686
Mailing Address - Country:US
Mailing Address - Phone:586-778-6090
Mailing Address - Fax:586-778-1943
Practice Address - Street 1:28300 HARPER AVE
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1686
Practice Address - Country:US
Practice Address - Phone:586-778-6090
Practice Address - Fax:586-778-1943
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHP047131207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3113474Medicaid
MIB47089Medicare UPIN
MI3113474Medicaid