Healthcare Provider Details

I. General information

NPI: 1730822081
Provider Name (Legal Business Name): SANDEEP BUDDHARAJU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LAKE DR SE STE 200
GRAND RAPIDS MI
49546-8292
US

IV. Provider business mailing address

4100 LAKE DR SE STE 200
GRAND RAPIDS MI
49546-8292
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-8244
  • Fax: 616-267-7272
Mailing address:
  • Phone: 616-267-8244
  • Fax: 616-267-7272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4301514936
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: