Provider Demographics
NPI:1154745933
Name:MYKIDZDOC LLC
Entity type:Organization
Organization Name:MYKIDZDOC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:
Authorized Official - First Name:OSAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-263-8984
Mailing Address - Street 1:48558 WOODSON WAY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6675
Mailing Address - Country:US
Mailing Address - Phone:773-263-8984
Mailing Address - Fax:
Practice Address - Street 1:48558 WOODSON WAY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-6675
Practice Address - Country:US
Practice Address - Phone:773-263-8984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301095767208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301095767Medicaid