Provider Demographics
NPI:1699755181
Name:DAS, DIPAK K (MD)
Entity type:Individual
Prefix:DR
First Name:DIPAK
Middle Name:K
Last Name:DAS
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 1:4040 LAKERIDGE LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1622
Mailing Address - Country:US
Mailing Address - Phone:248-538-7722
Mailing Address - Fax:
Practice Address - Street 1:995 FORD AVENUE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192
Practice Address - Country:US
Practice Address - Phone:734-284-3100
Practice Address - Fax:734-284-8212
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDD032902207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1042102110Medicaid
MION11710002Medicare ID - Type Unspecified
MI1042102110Medicaid