Healthcare Provider Details

I. General information

NPI: 1518178813
Provider Name (Legal Business Name): LAKSHMI KOCHARLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 FOREMOST DR SE STE 202
GRAND RAPIDS MI
49546-7062
US

IV. Provider business mailing address

5800 FOREMOST DR SE STE 300
GRAND RAPIDS MI
49546-7062
US

V. Phone/Fax

Practice location:
  • Phone: 833-850-0888
  • Fax:
Mailing address:
  • Phone: 833-850-0888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number4301081558
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: