Provider Demographics
NPI:1124196548
Name:REVANKAR, VARSHA S (MD)
Entity type:Individual
Prefix:
First Name:VARSHA
Middle Name:S
Last Name:REVANKAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VARSHA
Other - Middle Name:K
Other - Last Name:VERNEKAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5625 WATER TOWER PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2674
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-625-2622
Practice Address - Street 1:5625 WATER TOWER PL STE 200
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2674
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-2622
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI497485210Medicaid
VR087980OtherCHAMPUS-CHAMPUS
MI700F375500OtherBCBSM
MIM89900072Medicare PIN
MI700F375500OtherBCBSM