Healthcare Provider Details

I. General information

NPI: 1720267800
Provider Name (Legal Business Name): AMITHA KAKULAVARAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44200 WOODWARD AVE STE 209
PONTIAC MI
48341-5045
US

IV. Provider business mailing address

5280 METROPOLITAN PKWY
STERLING HEIGHTS MI
48310-4005
US

V. Phone/Fax

Practice location:
  • Phone: 248-253-0330
  • Fax: 248-253-1982
Mailing address:
  • Phone: 248-858-3011
  • Fax: 800-414-1646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301084121
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301084121
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4301084121
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: