Provider Demographics
NPI:1487252573
Name:VYAS, RUTVI HARSHADBHAI
Entity type:Individual
Prefix:
First Name:RUTVI
Middle Name:HARSHADBHAI
Last Name:VYAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19835 ASHLEY CT
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4027
Mailing Address - Country:US
Mailing Address - Phone:732-306-5109
Mailing Address - Fax:
Practice Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2576
Practice Address - Country:US
Practice Address - Phone:732-306-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDTP7181223X0008X
MI2901602094390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology