Basic Information
| Provider Information | |||||||||
| NPI: | 1427029453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOHINDRA | ||||||||
| FirstName: | AMIT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14555 LEVAN RD | ||||||||
| Address2: | STE. 112 | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481545083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347792123 | ||||||||
| FaxNumber: | 7347792163 | ||||||||
| Practice Location | |||||||||
| Address1: | 14555 LEVAN RD | ||||||||
| Address2: | STE. 112 | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481545083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347792123 | ||||||||
| FaxNumber: | 7347792163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 03/19/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301074778 | MI | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1108238712 | 01 | MI | BCBS OF MI | OTHER | 0P17890 | 01 | MI | MEDICARE PLUS BLUE | OTHER |