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General NPI Number Information
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NPI Number | 1629216007
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Entity Type | Individual
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Provider Name | LAKSHMI SUBBA NELLUTLA MD
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Gender | Female
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Dates
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Enumeration Date | 01/23/2009
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Last Update Date | 10/06/2010
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Provider Practice Location Address
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Address Line | 7733 E JEFFERSON AVE
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City | DETROIT
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State | MI
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Zip | 48214-3707
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Country | US
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Telephone | 313-499-4900
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Fax | 313-499-4483
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Provider Business Mailing Address
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Address Line | 17197 N LAUREL PARK DR SUITE 161
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City | LIVONIA
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State | MI
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Zip | 48152-2680
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Country | US
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Telephone | 734-338-8300
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Fax | 734-338-8301
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301093294
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License Number State | MI
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