Provider Demographics
NPI:1720652662
Name:UPADHYAY, MANOJ (MBBS)
Entity type:Individual
Prefix:
First Name:MANOJ
Middle Name:
Last Name:UPADHYAY
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HURLEY PLAZA
Mailing Address - Street 2:GME OFFICE 10W
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5902
Mailing Address - Country:US
Mailing Address - Phone:810-262-9080
Mailing Address - Fax:810-262-9080
Practice Address - Street 1:1 HURLEY PLAZA
Practice Address - Street 2:GME OFFICE 10W
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-262-9080
Practice Address - Fax:810-262-9080
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-15
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351047977390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty