Healthcare Provider Details

I. General information

NPI: 1619470473
Provider Name (Legal Business Name): MR. DHEERAJ KOTHAKONDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 W AVON RD
ROCHESTER HILLS MI
48307-2705
US

IV. Provider business mailing address

2642 BEACON HILL DR APT 103
AUBURN HILLS MI
48326-3726
US

V. Phone/Fax

Practice location:
  • Phone: 248-656-6331
  • Fax: 248-656-3216
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501015018
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: