Healthcare Provider Details

I. General information

NPI: 1942433289
Provider Name (Legal Business Name): NOBIN J KOTTUKAPALLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2009
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S MERRIMAN RD SUITE 100
WESTLAND MI
48186-5539
US

IV. Provider business mailing address

50375 UPTOWN AVE
CANTON MI
48187-6662
US

V. Phone/Fax

Practice location:
  • Phone: 585-279-4800
  • Fax: 585-244-9048
Mailing address:
  • Phone: 810-877-0848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number266204
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301094236
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: