Healthcare Provider Details

I. General information

NPI: 1376823286
Provider Name (Legal Business Name): SHABANA KALLADI PUTHANPURAYIL M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 W 13 MILE RD STE 707
ROYAL OAK MI
48073-6770
US

IV. Provider business mailing address

130 TOWN CENTER DR STE 203
TROY MI
48084-1744
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-0487
  • Fax: 248-551-3696
Mailing address:
  • Phone: 248-585-8250
  • Fax: 248-585-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number4301097882
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301097882
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: