Healthcare Provider Details

I. General information

NPI: 1053620617
Provider Name (Legal Business Name): MADAIAH KUSUMA-TALAKADU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 N MACOMB ST
MONROE MI
48162-3085
US

IV. Provider business mailing address

814 N MACOMB ST
MONROE MI
48162-3085
US

V. Phone/Fax

Practice location:
  • Phone: 734-243-5720
  • Fax: 734-243-9261
Mailing address:
  • Phone: 734-243-5720
  • Fax: 734-243-9261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301096025
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: