MEDICARE: POOJA KODALI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301511158	MI

General Provider Information

NPI Number	:	1477040608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	POOJA KODALI MD

Provider Business Mailing Address
First Line	:	16828 HORSESHOE DR
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48168-8586
Country	:	US
Telephone Number	:	248-277-8703
Fax Number	:

Provider Business Practice Location Address
First Line	:	16226 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-1824
Country	:	US
Telephone Number	:	313-836-5491
Fax Number	:	313-836-5224

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2018
Last Update Date	:	04/19/2024

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Directions to “ POOJA KODALI MD” Practice Location

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