Healthcare Provider Details

I. General information

NPI: 1942719125
Provider Name (Legal Business Name): ARCHANA REDDY BONGURALA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 WEST 13 MILE RD SOUTH CLINIC
ROYAL OAK MI
48073
US

IV. Provider business mailing address

3535 W 13 MILE RD
ROYAL OAK MI
48073-6770
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-3000
  • Fax: 248-551-2032
Mailing address:
  • Phone: 248-551-3000
  • Fax: 248-551-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301112602
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: