MEDICARE: DR. KAVITHA PONDURI M.D.

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	207R00000X	Internal Medicine Physician	4301063347	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679568315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAVITHA PONDURI M.D.

Provider Business Mailing Address
First Line	:	34659 W MICHIGAN AVE
Second Line	:
City	:	WAYNE
State	:	MI
Zip	:	48184-1730
Country	:	US
Telephone Number	:	734-722-2400
Fax Number	:	734-722-1709

Provider Business Practice Location Address
First Line	:	34659 W MICHIGAN AVE
Second Line	:
City	:	WAYNE
State	:	MI
Zip	:	48184-1730
Country	:	US
Telephone Number	:	734-722-2400
Fax Number	:	734-722-1709

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	12/25/2017

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