Healthcare Provider Details

I. General information

NPI: 1124438445
Provider Name (Legal Business Name): MADHUMITHA KRISHNAMOORTHY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26400 W 12 MILE RD STE 110
SOUTHFIELD MI
48034-1771
US

IV. Provider business mailing address

26400 W 12 MILE RD STE 110
SOUTHFIELD MI
48034-1771
US

V. Phone/Fax

Practice location:
  • Phone: 734-707-8086
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number43011053135
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: