Healthcare Provider Details

I. General information

NPI: 1265458624
Provider Name (Legal Business Name): HIMAJA GUMMADI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30901 PALMER RD
WESTLAND MI
48186-9529
US

IV. Provider business mailing address

172 QUEEN ANNE DR
CANTON MI
48187-4682
US

V. Phone/Fax

Practice location:
  • Phone: 734-367-8403
  • Fax: 734-722-9524
Mailing address:
  • Phone: 734-397-1805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301070128
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: