Basic Information
| Provider Information | |||||||||
| NPI: | 1942738448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAIRIKAR | ||||||||
| FirstName: | MUGDHA | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | WAGH | ||||||||
| OtherFirstName: | MONICA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22201 MOROSS RD STE 80 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482362166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133433800 | ||||||||
| FaxNumber: | 3133434756 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 BATES AVE STE 245 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328243834 | ||||||||
| FaxNumber: | 8328259330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2017 | ||||||||
| LastUpdateDate: | 06/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4301112227 | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.