Provider Demographics
NPI:1124471933
Name:KANDOLA, MONICA (MD)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:KANDOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18272 W 12 MILE RD
Mailing Address - Street 2:APT 204
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2669
Mailing Address - Country:US
Mailing Address - Phone:313-742-2855
Mailing Address - Fax:
Practice Address - Street 1:210 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-2048
Practice Address - Country:US
Practice Address - Phone:248-437-1744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-16
Last Update Date:2016-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301110447390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program