Provider Demographics
NPI:1407047780
Name:JEETENDER MATHARU MD PLC
Entity type:Organization
Organization Name:JEETENDER MATHARU MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEETENDER
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATHARU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-620-3500
Mailing Address - Street 1:7250 DIXIE HWY
Mailing Address - Street 2:STE 100
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5108
Mailing Address - Country:US
Mailing Address - Phone:248-620-3500
Mailing Address - Fax:248-620-3503
Practice Address - Street 1:7250 DIXIE HWY
Practice Address - Street 2:STE 100
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5108
Practice Address - Country:US
Practice Address - Phone:248-620-3500
Practice Address - Fax:248-620-3503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4483424Medicaid
MIH21599Medicare UPIN
MI4483424Medicaid