Healthcare Provider Details

I. General information

NPI: 1457352676
Provider Name (Legal Business Name): CHILAKAPATI VIJAYA KUMAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHILAKAPATI VIJAYA KUMAR MD

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14752 NORTHLINE RD
SOUTHGATE MI
48195-2467
US

IV. Provider business mailing address

PO BOX 77000 DEPT 771255
DETROIT MI
48277-4085
US

V. Phone/Fax

Practice location:
  • Phone: 734-285-5030
  • Fax: 734-285-8223
Mailing address:
  • Phone: 313-271-3000
  • Fax: 313-271-3003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301040566
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: