Provider Demographics
NPI:1215949060
Name:DALAL, KANU B (MD)
Entity type:Individual
Prefix:
First Name:KANU
Middle Name:B
Last Name:DALAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1221 PINE GROVE AVE
Mailing Address - Street 2:RADIOLOGY DEPT
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3511
Mailing Address - Country:US
Mailing Address - Phone:810-987-5000
Mailing Address - Fax:810-985-0032
Practice Address - Street 1:1221 PINE GROVE AVE
Practice Address - Street 2:RADIOLOGY DEPT
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3511
Practice Address - Country:US
Practice Address - Phone:810-987-5000
Practice Address - Fax:810-985-0032
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI0429342085R0202X
MI43010429342085R0203X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1947181Medicaid
MI1947181Medicaid
B48274Medicare UPIN