Provider Demographics
NPI:1992921621
Name:SAMPATH, PRAVEENA (MD)
Entity type:Individual
Prefix:MRS
First Name:PRAVEENA
Middle Name:
Last Name:SAMPATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 DORCHESTER DR N
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3777
Mailing Address - Country:US
Mailing Address - Phone:248-614-3114
Mailing Address - Fax:
Practice Address - Street 1:1455 S LAPEER RD
Practice Address - Street 2:SUITE 134
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1467
Practice Address - Country:US
Practice Address - Phone:248-683-3385
Practice Address - Fax:248-683-8441
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010776942080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301077694OtherSTATE LICENSE