1205836137 NPI number — DR. SHYLAJA KHATIWALA MD

Table of content: DR. SHYLAJA KHATIWALA MD (NPI 1205836137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205836137 NPI number — DR. SHYLAJA KHATIWALA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHATIWALA
Provider First Name:
SHYLAJA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205836137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8444 N 90TH ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85258-4437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-248-8886
Provider Business Mailing Address Fax Number:
480-687-7361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25639 FORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48127-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-248-8886
Provider Business Practice Location Address Fax Number:
480-687-7361
Provider Enumeration Date:
07/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301076421 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1205836137 . This is a "BCBS TYPE 1 (IND) NPI #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P37000001 . This is a "MEDICARE IND PIN #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5315052867 . This is a "CDS #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 11438804 . This is a "CAQH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301076421 . This is a "STATE LICENSE #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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