Basic Information
Provider Information | |||||||||
NPI: | 1255323747 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEWAR | ||||||||
FirstName: | SHENBAGAM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VEERAPUTHIRAN | ||||||||
OtherFirstName: | SHENBAGAM | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D., | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3621 SOUTH STATE STREET | ||||||||
Address2: | 700 KMS PLACE | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 48108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7349362047 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 564 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | WALTHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 024525516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7816933800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2005 | ||||||||
LastUpdateDate: | 10/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 230753 | MA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 4301108515 | MI | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207RG0300X | 4301108515 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | GR0003490 | 05 | CA |   | MEDICAID | 00A871530 | 05 | CA |   | MEDICAID |