Healthcare Provider Details

I. General information

NPI: 1073794764
Provider Name (Legal Business Name): PRATIMA BOINEPALLI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3945 OKEMOS RD STE A1
OKEMOS MI
48864-4207
US

IV. Provider business mailing address

3945 OKEMOS RD STE A1
OKEMOS MI
48864-4207
US

V. Phone/Fax

Practice location:
  • Phone: 517-295-5000
  • Fax: 517-507-5424
Mailing address:
  • Phone: 517-295-5000
  • Fax: 517-507-5424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301085879
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: