Provider Demographics
NPI:1316790447
Name:AMALATHASAN, THEBUOSHON (MD)
Entity type:Individual
Prefix:
First Name:THEBUOSHON
Middle Name:
Last Name:AMALATHASAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15855 19 MILE RD, CLINTON TWP, MI 48038, USA
Mailing Address - Street 2:
Mailing Address - City:15855 19 MILE RD, CLINTON TWP, MI 48038,
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-263-2300
Mailing Address - Fax:
Practice Address - Street 1:15855 19 MILE RD, CLINTON TWP, MI 48038, USA
Practice Address - Street 2:
Practice Address - City:15855 19 MILE RD, CLINTON TWP, MI 48038,
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-263-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program