Provider Demographics
NPI:1972573061
Name:ATWAL, MANDIP S (DO)
Entity type:Individual
Prefix:DR
First Name:MANDIP
Middle Name:S
Last Name:ATWAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1030 HARRINGTON ST
Mailing Address - Street 2:SUITE 302A
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2967
Mailing Address - Country:US
Mailing Address - Phone:586-759-2005
Mailing Address - Fax:586-759-2636
Practice Address - Street 1:1030 HARRINGTON ST
Practice Address - Street 2:302A
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2967
Practice Address - Country:US
Practice Address - Phone:586-759-2005
Practice Address - Fax:586-759-2636
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMA012641208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0255004485OtherBCBS PIN
MI0255010915OtherBCBS
MI114528179Medicaid
MI114528179Medicaid
MI0N76210002Medicare PIN
MI0P32120003Medicare PIN