Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2084N0400X | Neurologist | 4301052512 | MI |
NPI | 1003991191 |
---|---|
Provider Name | Ravinder Mediratta |
First Address | Portage, MI 49024-1296 |
Second Address | Portage, MI 49024-1296 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2006 |
Last Update Date | 31/12/2012 |