Basic Information
| Provider Information | |||||||||
| NPI: | 1750332193 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASHISHTA | ||||||||
| FirstName: | GAURAV | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28411 NORTHWESTERN HWY | ||||||||
| Address2: | SUITE #1050 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480345544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483544709 | ||||||||
| FaxNumber: | 2483544807 | ||||||||
| Practice Location | |||||||||
| Address1: | 27211 LAHSER RD | ||||||||
| Address2: | SUITE # 200 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480348469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483584892 | ||||||||
| FaxNumber: | 2483585125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | GV081359 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110F336360 | 01 | MI | BCBSM | OTHER | 1346398971 | 01 | MI | GROUP NPI | OTHER | 205485614 | 01 | MI | TAX ID | OTHER | 4301081359 | 01 | MI | LICENSE | OTHER | 207R00000X | 01 | MI | TAXOMOMY | OTHER | 104934122 | 05 | MI | MEDICAID |