Healthcare Provider Details

I. General information

NPI: 1477755031
Provider Name (Legal Business Name): LALATHAKSHA M KUMBAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2711
  • Fax: 313-916-2554
Mailing address:
  • Phone: 313-916-2711
  • Fax: 313-916-2554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301096740
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code246ZN0300X
TaxonomyNephrology Specialist/Technologist
License Number4301096740
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301096740
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: