Provider Demographics
NPI:1174585251
Name:AYSOLA, PADMA (MD)
Entity type:Individual
Prefix:DR
First Name:PADMA
Middle Name:
Last Name:AYSOLA
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 1:30129 DEER RUN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-6010
Mailing Address - Country:US
Mailing Address - Phone:248-474-9866
Mailing Address - Fax:248-474-9867
Practice Address - Street 1:19930 FARMINGTON RD STE C
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1440
Practice Address - Country:US
Practice Address - Phone:248-474-9866
Practice Address - Fax:248-474-9867
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPA038608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383633568OtherTAX ID
MI0P21790Medicare ID - Type Unspecified
MI383633568OtherTAX ID