Healthcare Provider Details

I. General information

NPI: 1841286937
Provider Name (Legal Business Name): KATIKINENI V RAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 4TH ST
JACKSON MI
49203-4518
US

IV. Provider business mailing address

2100 4TH ST
JACKSON MI
49203-4518
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-4332
  • Fax: 517-787-4861
Mailing address:
  • Phone: 517-787-4332
  • Fax: 517-787-4861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301031905
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: