Healthcare Provider Details

I. General information

NPI: 1467078857
Provider Name (Legal Business Name): ANIRUDH KOTHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date: 01/17/2022
Reactivation Date: 02/01/2022

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: