Basic Information
| Provider Information | |||||||||
| NPI: | 1639444748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ICECREAMWALA | ||||||||
| FirstName: | DEVIKA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PATEL | ||||||||
| OtherFirstName: | DEVIKA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4201 ST. ANTOINE - UHC 5D - MAILBOX #226 | ||||||||
| Address2: | UNIVERSITY PEDIATRICIANS | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454405 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 DUBLIN BLVD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945683113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9258756100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 4301103562 | MI | N | Allopathic & Osteopathic Physicians | Dermatology | 207NP0225X | 4301103562 | MI | N | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology | 208000000X | 4301103562 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 207N00000X | 148974 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.