Healthcare Provider Details

I. General information

NPI: 1437251915
Provider Name (Legal Business Name): VISHNU NUTAKKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E MICHIGAN AVE
GRAYLING MI
49738-1312
US

IV. Provider business mailing address

PO BOX 545
GRAYLING MI
49738-0545
US

V. Phone/Fax

Practice location:
  • Phone: 989-348-5461
  • Fax:
Mailing address:
  • Phone: 989-348-1040
  • Fax: 989-348-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301067348
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: