Provider Demographics
NPI:1730167552
Name:WALAVALKAR, SUDHIR (MD)
Entity type:Individual
Prefix:
First Name:SUDHIR
Middle Name:
Last Name:WALAVALKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25925 TELEGRAPH RD
Mailing Address - Street 2:210
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2518
Mailing Address - Country:US
Mailing Address - Phone:248-746-3218
Mailing Address - Fax:248-746-0369
Practice Address - Street 1:22255 GREENFIELD RD
Practice Address - Street 2:310
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3710
Practice Address - Country:US
Practice Address - Phone:248-849-4990
Practice Address - Fax:248-849-4991
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301041018207R00000X
MISW041018207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A76638Medicare UPIN
MI0F36477Medicare PIN