Healthcare Provider Details

I. General information

NPI: 1477040608
Provider Name (Legal Business Name): POOJA KODALI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16226 GRAND RIVER AVE
DETROIT MI
48227-1824
US

IV. Provider business mailing address

16828 HORSESHOE DR
NORTHVILLE MI
48168-8586
US

V. Phone/Fax

Practice location:
  • Phone: 313-836-5491
  • Fax: 313-836-5224
Mailing address:
  • Phone: 248-277-8703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301511158
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: