Provider Demographics
NPI:1316130172
Name:CHOUDHARY, SHIVANI (MD)
Entity type:Individual
Prefix:DR
First Name:SHIVANI
Middle Name:
Last Name:CHOUDHARY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8203 S SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2434
Mailing Address - Country:US
Mailing Address - Phone:810-875-0566
Mailing Address - Fax:
Practice Address - Street 1:8203 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2434
Practice Address - Country:US
Practice Address - Phone:810-875-0566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086642208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3502514032OtherBLUE CROSS BLUE SHIELD OF MICHIGAN PROVIDER ID#
MIOB57611OtherBLUE CROSS BLUE SHIELD OF MICHIGAN - PEDIATRIC GROUP
MIOM29310Medicare PIN