Basic Information
| Provider Information | |||||||||
| NPI: | 1700823291 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOUDGAL | ||||||||
| FirstName: | VARSHA | ||||||||
| MiddleName: | VIVEK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DR | ||||||||
| Address2: | PO BOX 0446 LOBBY J | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347476766 | ||||||||
| FaxNumber: | 7342223100 | ||||||||
| Practice Location | |||||||||
| Address1: | 5333 MCAULEY DR | ||||||||
| Address2: | STE 6109 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481970000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347128600 | ||||||||
| FaxNumber: | 7347128636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 09/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | VM071985 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 4301071985 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 4895454-10 | 05 | MI | MEDICAID |