Provider Demographics
NPI:1992899546
Name:MEWADA, MANILAL O (MD)
Entity type:Individual
Prefix:
First Name:MANILAL
Middle Name:O
Last Name:MEWADA
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 1:4001 WALLI STRASSE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1729
Mailing Address - Country:US
Mailing Address - Phone:810-743-5400
Mailing Address - Fax:810-743-5474
Practice Address - Street 1:4001 WALLI STRASSE
Practice Address - Street 2:SUITE C
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1729
Practice Address - Country:US
Practice Address - Phone:810-743-5400
Practice Address - Fax:810-743-5474
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041950207Q00000X, 208D00000X
MIMM041950207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1566962Medicaid
MI1602508232OtherBLUE CROSS BLUE SHIELD
MI0250823Medicare ID - Type UnspecifiedPROVIDER ID NUMBER
MIA76179Medicare UPIN