Healthcare Provider Details

I. General information

NPI: 1740412626
Provider Name (Legal Business Name): PURNACHANDER RAO VANGALA M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31095 FLORALVIEW DR S 105
FARMINGTON HILLS MI
48331-5862
US

IV. Provider business mailing address

31095 FLORALVIEW DR S APT 105
FARMINGTON HILLS MI
48331-5863
US

V. Phone/Fax

Practice location:
  • Phone: 616-206-0159
  • Fax:
Mailing address:
  • Phone: 616-206-0159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2016-01861
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301094738
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: